VA Mid-Atlantic Health Care Network (VISN 6)

Issue: VA employee A sent a peer review form containing the full name, full SSN, DoB, and diagnosis of a patient to VA employee B through interoffice mail. The documents were never received by VA employee B. The documents have not…

Outcome: The current process is to NOT send the peer review forms via interoffice mail. Employee hand delivers and picks them up when complete. The employee plans to avoid this in the future by using a different style envelope to transport…

Issue: A Veteran received a travel voucher for another veteran who has the same name. The Veteran's SSN was not verified before the travel voucher was mailed. Update: 03/21/12:Veteran B will be sent a letter offering credit protection services.…

Outcome: HAS Supervisor established new standard operating procdures for the travel clerks. The travel voucher must be verified before it is mailed. If the travel clerk is unable to verify the veteran's social security number or any personally identifiable information, the…

Issue: An inpatient ward roster containing information of 21 Veterans was found by a VA employee outside the grounds of a local restaurant within walking distance of the VA Medical Center. Update: 03/19/12:All 21 Veterans will be sent letters offering credit…

Outcome: The responsible employee re-took the privacy training, received a verbal warning and his supervisor is taking the time to alert the entire staff of the importance of not leaving the facility with inpatient ward rosters.

Issue: Veteran A received laboratory results for Veteran B which included his name, address and protected health information (PHI). Update: 03/19/12:Veteran B will receive a letter of notification.…

Outcome: Privacy Officer provided education and training to HAS staff members regarding the mailing of protected health information. PO reviewed Mail Directive 6609 with staff. Privacy Officer provided the Privacy Fact sheet on the Disclosure of Protected Health and Individually Identifiable…

Issue: Release of information staff released the following information to one Veteran: 15 full names of other Veterans; six full names and addresses of other Veterans; and two Veteran's full name, full social security number, date of birth, admission and discharge…

Outcome: Responsible service is in the process of educating all staff as well as taking disciplinary action.

Issue: A Field Service Officer (FSO) from the Disabled American Veterans brought a CD containing Veteran A's medical record and Veteran B's medical record. Veteran A, who brought the CD to the FSO did not open the package the CD came…

Outcome: HIMS Chief investigated this incident and found that the CD burning software they use sometimes stores information from the last CD burned. HIMS Chief conducted education and training to ROI staff to ensure this type of issue does not happen…

Issue: A Social Worker faxed a VA form 10-0103 (Veterans Application for Assistance in Acquiring Home Improvement) to a fax number she was given by a co-worker. The fax number she was given was incorrect. Update: 03/06/12:The Veteran whose information was…

Outcome: Social Worker was given retraining by the PO on the proper way to fax information. PO also sent the same instructions to all supervisors and instructed them to inform their employees.

Issue: Employee A approached Employee B and asked Employee B to log into computer program allegedly because she could not access the file through her login. Employee B did permit Employee A to access the information through Employee A's login. Employee…

Outcome: Counseling and remedial training was provided. Case referred to service chief for administrative action.…

Issue: Veteran A received the progress notes and lab results of Veteran B following a release of information request. The information disclosed included Veteran B's name, address, date of birth, full SSN and protected health information (PHI). Update: 02/29/12:Veteran B will…

Outcome: Responsible service is in the process of educating all staff as well as taking disciplinary action.

Issue: A VA staff member found chart stickers of a Veteran/Patient from ICU on the loading dock next to and around the trash compactor. The stickers included full name SSN, and DOB. Update: 03/05/12:One (1) Veteran will be sent a letter…

Outcome: Provided additional training to ICU staff regarding proper disposal of PII.