VA Mid-Atlantic Health Care Network (VISN 6)

Issue: Patient A was discharged from the Emergency Department on 12/13/11 and was given the discharge paperwork for Patient B by a resident. Patient A realized this when he went back to his inpatient room. Patient A's roommate took the discharge…

Outcome: Doctor was verbally counseled by the Chief of the Emergency Department.

Issue: On December 10, 2011 a patient was transferred to another unit within the hospital. A nurse was stripping the bed for EMS and found under the head of the mattress six unfolded pieces of paper containing patient information for six…

Outcome: After investigation, unable to determine any responsibility for the action. All employees take annual security/privacy training.…

Issue: Veteran A received medication that belonged to Veteran B. Update: 12/09/11:Veteran B will be sent a notification letter.…

Outcome: Interim Pharmacy Chief has provided education to Pharmacy personnel regarding the standard operating procedures for dispensing medications to Veterans. Pharmacy personnel are instructed to check the contents of each bag given to the veteran to validate the veteran receives the…

Issue: Employee A discovered Employee B's college transcript scanned into his eOPF. Update: 12/08/11:Employee B will be sent a letter offering credit protection services.…

Outcome: All HR staff involved in scanning have had review of proper procedures and cautioned about importance of accuracy in their responsibilities.

Issue: A VA employee transferred to another VA facility. His employee peronnel records were delivered to the new facility but cannot be located. Update: 12/07/11:Employee A will be sent a letter offering credit protection services.…

Outcome: All mail clerks etc have been retrained in the proper handling of incoming mail.

Issue: On Sunday, November 20, 2011 the police stopped a Veteran who was not in a clinic area in the hospital. When they questioned him and searched his belongings, they found patient health information for three Veterans. They confiscated the patient…

Outcome: Police have verified this Veteran is in jail. He is also a mental health patient and we have no expectation that the police will be able to verify how he obtained patient health information at Durham and the other VA…

Issue: Veteran A requested copies of his medical records be mailed to him. When Veteran A received them in the mail, he realized that three lab results for Veteran B had also been included. Veteran A hand carried Veteran B's three…

Outcome: Staff was provided additional training and the system to monitor envelopes prepared for mailing was also reviewed.

Issue: The unit reports for units MICU, 9A, 7B, 6B, and 6A were not delivered to the correct location at midnight on 11/08/11. These documents contained 17 patients' full name, last four digits of the SSN, and notes such as "restraints",…

Outcome: Contact has been made with the vendor who provides Escort services. The COTR plans to identify and remove all Escort tasks requiring the handling/transporting of documents that contain protected health information within the next 3 weeks.…

Issue: On 10/14/11, VA Employee A accessed VA Employee B's electronic medical record to obtain Employee A's phone number for personal reasons. The inappropriate access was discovered through a routine review by the Information Security Officer (ISO). The incident was reported…

Outcome: The Supervisor spoke with Employee A on 11/09/11 and verbally counseled employee A regarding the privacy violation.

Issue: A Nurse Manager discovered that a VA employee was keeping files on numerous employees. The information included performance appraisals, background investigations, medical records, education records, etc, that went back to 1985. Update: 11/10/11: The Privacy Officer (PO) reported that it…

Outcome: The site has implemented record management procedures t ensure personally protected information is dispositional properly.