VA Mid-Atlantic Health Care Network (VISN 6)

Issue: Veteran A received a copy of an X-Ray for Veteran B as part of a release of information request. Update: 09/27/11:Due to date of birth being exposed, Veteran B will be sent a letter offering credit protection services.…

Outcome: Remedial training completed. Referred to service chiefs for appropriate administrative action.…

Issue: A Fax sent to the correct number but an incorrect area code. The recipient immediately contacted VA. The employee was identified. The patient and his wife still on ward. The patient was immediately notified. The recipient agreed to return the…

Outcome: Reviewed with staff faxing process and procedures.

Issue: A research compliance audit revealed a consent form could not be located. Consent was obtained on 2/25/11 but then withdrawn on 2/26/11. The form was not scanned into CPRS, and cannot be located. Update: 09/13/11:One Veteran will be sent a…

Outcome: Staff re-trained regarding consent procedures. Credit monitoring letter sent to Veteran.…

Issue: A VA employee was arrested on 9/5/2011 by county (non-VA) law enforcement. Found in his car and in his home was an "inpatient bed roster" dated August 23, 2011 containing room number, full name, full SSN, age, admission date and…

Outcome: Computer/network access has been disabled and the employee has been referred for further action.

Issue: A Release of Information (ROI) employee released Veteran A's discharge summary from October 7, 2009 on April 5, 2010. The ROI employee could not recall the details of the release. A Court Order for Appointment of Guardian ad Litem was…

Outcome: VA employee was issued a written counseling statement on April 1, 2011 by his supervisor. Additionally, actions to identify Veterans who request information from ROI in person is being better documented.…

Issue: A licensed practical nurse (LPN), dispensed a set of stool occult blood cards without confirming the identity of the recipient, and handed the set of cards to Patient A. The cards included Patient B's name, Social Security Number, and date…

Outcome: The individuals supervisor re educated the staff member on properly identifying patients.

Issue: VA Employee A delivered VA form for computer access and rules of behavior to VA employee B unsecured. This VA form contained information regarding VA employee C (name, SSN, address, phone, email, date of birth, gender). VA Employee B was…

Outcome: VA employee A counseled.

Issue: A VA form 10-5345 (release of information) was found unsecured in the mail room by VA Employee A. The release of information form included Veteran A's name and full social security number. VA Employee A brought the form to VA…

Outcome: All mail room employees were reminded to place any unsecured patient health information in a VA envelope and give directly to the PO if uncertain where information should go. Also, CBOC staff have a process in place but will be…

Issue: Documents concerning 9 Employees drivers licenses was sent in inter office mail. Mail room cannot verify that they received it. The end user of the mail, the state of North Carolina did not receive the documents. The information on the…

Outcome: Staff received additional training on safeguarding documents and security of same. Procedural issue being addressed by service chief.…

Issue: Veteran A received medication in the mail with an information sheet for Veteran B. Update: 07/07/11:Veteran B will receive a letter of notification.…

Outcome: Responsible party received administrative action that included refresher training from supervisor. Procedures also being addressed.…