VA Mid-Atlantic Health Care Network (VISN 6)

Issue: Veteran A received Veteran B's medical records in error. Veteran A mailed medical records to Veteran B. Veteran B then notified the VA. Update: 03/25/13:Duet to full SSN and medical information being exposed, Veteran B will be sent a letter…

Outcome: Veteran B refused to return the medical records as they belonged to him. As of this date and time, it has not been determined how Veteran A received Veteran B's medical records. The Durham VA is not sure Person A…

Issue: Mailing labels for medical supplies contained Veterans SSNs. There were two previous reports; however upon having the Vendor review the two days in question it was discovered that 33 additional Veterans' had their SSN printed on the mailing labels. Update:…

Outcome: Procedures for the mailing of the pharmacy supplies has been corrected. No SSN will print in the new labels.…

Issue: A Medical Support Assistant (MSA) at a Community Based Outpatient Clinic (CBOC) stated to a mental health LPN. "You need to talk to this person. He is the Mental Health person waiting to see you." This happened while the Veteran…

Outcome: Associate Chief in HAS will provide corrective action to the VA employee in HAS regarding the violation to the veteran's auditory privacy. VA employee has completed Privacy and HIPAA training.

Issue: A wristband was placed on the wrong patients in the Emergency Department (ED). Veteran A was seen in the Emergency Department, Veteran states a wrist band was placed. She went home and realized the wrist band she had on was…

Outcome: Supervisor provided documentation that Staff have been re-educated on properly identifying patients prior to placing wristbands on patients.

Issue: An appointment letter was mailed out to the Veteran without being enclosed in an envelope. The letter was scanned out our facility with postage and was mailed to the Veteran. Update: 03/15/13:The Veteran will be sent a letter of notification.05/16/13:This…

Outcome: Supervisor established updated QA from Mailroom staff prior to applying postage to mail.

Issue: Two prescriptions for the same medication were filled on 02/07/13 and sent via UPS. The addresses were transposed and sent to the wrong Veterans. Update: 03/13/13:Both Veterans will receive a HIPAA letter of notification.…

Outcome: Supervise notes he re-trained staff ton he importance of double checking the patient name on the prescription bottle being placed in the UPS package and to ensure that the name on the prescription matches the name on the UPS shipping…

Issue: On 03/11/13 at 1:30 PM, the Privacy Officer (PO) received a phone call from Veteran A stating that while visiting the Beckley VAMC on 03/05/13 in the Orange Clinic, she requested a copy of her upcoming appointments at the scheduling…

Outcome: On 3/11/13 supervisor over the scheduling clerks emailed the clerks (and copied the PO) reminding them that before giving out any paper that contains any personal information to a patient to take extra time and verify by at least two…

Issue: Veteran A and B are related and have same first and last name but different middle initial. Veteran A received the radiology image of Veteran B. When Veteran A viewed the image on his computer, he noticed that the image…

Outcome: The responsible service held a discussion with staff involved emphasizing the importance of accuracy and staff will retake Privacy and HIPAA Training immediately.

Issue: Veteran Employee requested to review the sensitive patient access report to review any inappropriate access to her medical record. Update: 05/22/13:Pending Office of Civil Rights compliant. (OCR) VHA Privacy Office requested PSETS ticket to be updated to an Incident due…

Outcome: PO provided training and education to the VA employee. PO reviewed the Privacy and Information Security Policy with the VA employee. PO provided information to Human Resources regarding the inappropriate access to the Veteran/Employee's medical record. HR/Labor Relations recommended a…

Issue: Veteran A received the demographics screen printed from CPRS of Veteran B. Veteran A turned in the papers to the Release of Information (ROI) office who notified the Privacy Officer (PO). At this time, it is not known how Veteran…

Outcome: It has not been possible to determine the responsible service. It is believed the demographics page was given to Veteran B and Veteran B left the paperwork in ROI offices by mistake. This is when Veteran A accidentally picked up…