VA Mid-Atlantic Health Care Network (VISN 6)

Issue: Medication and the Medication Information sheet for Veteran A was mailed out to Veteran B in error by Pharmacy. Update: 03/01/13:Veteran A will be sent a HIPAA notification letter.…

Outcome: Acting Pharmacy Chief to provide education and training to Pharmacy Tech to ensure medications are mailed correctly to the Veteran. Acting Chief will provide documentation to PO of the training and staff meeting documentation.

Issue: A Privacy Complaint from April 2012 was not entered into the Privacy and security Events Tracking System (PSETS). Per the VHA Privacy Office, the Privacy Complaint must be entered into PSETS. The Final Determination Letter was mailed to the Veteran…

Outcome: Privacy Officer provided training to the VA employees who accessed the Veteran's medical records. PO received additional information (claim form) from one VA employee in regards to the access to medical records to verify the Veteran's home address. PO uploaded…

Issue: An End of the Shift report and missing medication information which contains sensitive information was given to a Veteran along with a discharge summary. Update: 02/25/13:Ten Veterans will be sent letters offering credit protection services, as their names, full SSNs,…

Outcome: Ward staff has been reminded to review information provided to Veterans on discharge. Credit monitoring letters sent to Veterans (10) and a thank you letter sent to the reporting Veteran.…

Issue: Veteran A's medication was mislabeled with Veteran B's information. The protected health information (PHI) included full name and medication information. Update: 02/12/13:Veteran B will be sent a HIPAA notification letter.…

Outcome: Employee who committed the error was notified and proper procedures were reinforced.

Issue: Veteran A received paperwork in the mail and attached to his information was paperwork on Veteran B. Update: 02/07/13:Veteran B will be sent a letter offering credit protection services due to full name and SSN being disclosed.…

Outcome: On 2/8/13 PO prepared a letter to Veteran B for one year of free credit monitoring. Letter signed by BVAMC Director and mailed certified return-receipt requested on 2/13/13.The BVAMC HIMS Chief reminded ROI Clerks that they are to check every…

Issue: A contract physician released prescription information about a patient to a law enforcement agency without an authorization letter. Update: 02/06/13:Veteran A will be sent a notification letter.…

Outcome: A notification letter was sent to the patient. Targeted training was conducted by those directly involved, and more generalized training was done and will continue to be done at the facility level to raise awareness of proper authorizations, and accounting…

Issue: Veteran A reported to the OIG Hotline that his full SSN was printed on the mailing label for his ostomy supplies. Update: 02/01/13:Veteran A will receive a letter offering credit protection services.…

Outcome: Credit monitoring is being offered to the Veteran. The issue with the printing of mailing labels was corrected due to another case that was received.…

Issue: A Durham VA Prosthetics representative went to an off-site warehouse on 12/13/12 to remove VA equipment. The warehouse was owned by a vendor who was under OIG investigation and is no longer in business.They found a large trash barrel full…

Outcome: All paper associated with this privacy incident was recovered. The VA is no longer doing business with this particular vendor and the case was investigated by OIG.

Issue: Three laboratory specimen labels were found in the staff bathroom. Personally Identifiable Information (PII) was on the label included name, full SSN and the date of the specimen was collected. Update: 01/23/13:The Privacy Officer (PO) spoke with Assistant Chief of…

Outcome: Asst. Chief of Path/Laboratory Services informed PO the SOP for Processing Laboratory specimens will be revised and the Phlebotomy Supervisor will conduct training with her staff members to ensure compliance in protecting VA sensitive information.

Issue: The mailing label on supplies that were sent to the Veteran contained the Veteran's SSN. The Veteran and his spouse is very upset that this occurred. The Veteran & his wife checked with their bank about a possible breach, however…

Outcome: Mailing label program corrected. Pharmacy techincian checks labels to ensure that SSNs are not printed on mailing label.…