VA Mid-Atlantic Health Care Network (VISN 6)

Issue: Veteran A was given a Hemoccult test to take home. He discovered Veteran B's lab label on the test. The label contained Veteran B's name, date of birth, full SSN and Hemoccult test materials. Update: 01/10/13:Veteran B will receive a…

Outcome: Clinic staff has been reminded to review information give to Veterans prior to the final hand off.

Issue: Veteran received a Christmas card in the mail from VA employee. The Veteran had not disclosed home address and suspects the employee misused access to obtain her home address. Update: Interviewed employee in question regarding complaint. Employee admits to accessing…

Outcome: Discussed violation with employee who understands the error and agrees to abstain in the future. Employee Service Chief notified for appropriate administrative action. Complainant notified of aforementioned corrective action in close out letter.

Issue: Veteran A received the test results for Veteran B. Update: 12/28/12: Veteran B will be sent a HIPAA notification letter.…

Outcome: No Violation found. The letter received by the Veteran did not contain any protected health information. The Veteran's name was listed on the bottom of the letter. The contains information to call the Prime clinic to schedule an appointment.

Issue: Surgeon A took photos of a patient with personal camera for purposes of clinical documentation. The camera was stolen yesterday from his clinic area. The camera contained the image of the patient as well as full name and full SSN.…

Outcome: The responsible service has a standard operating procedure in place for providers who need to take photos of Veterans for clinical documentation. The provider in this case did not follow local procedure and the entire service has been reminded of…

Issue: Veteran Employee requested to review the sensitive patient access report to review any inappropriate access to her medical record. Update: 05/22/13:An employee accessed a Veteran/Employees medical record without a need to know. The Veteran/Employee will be sent a HIPAA notification…

Outcome: PO provided copies of the responses to Human Resources regarding the privacy complaint. The access was an inappropriate access to the veteran's medical record. PO provided education and training to the employee regarding the access and use of VA information…

Issue: A Pharmacist reported that Veteran A presented to the Pharmacy window looking for a multivitamin on his profile. After it was not found on the profile, the Veteran presented the progress note that belonged to Veteran B. Update: 12/11/12:Veteran B…

Outcome: PO interviewed veteran to investigate the employee who provided to progress note. The veteran was unable to provide the name of the employee. And gave a vague description of the nurse. PO unable to locate the nurse who provided the…

Issue: Veteran A received the clinical results for Veteran B. Veteran B's name, address and diagnosis were disclosed. Update: 12/07/12:Veteran A received the clinical results for Veteran B. Veteran B's name, address and diagnosis were disclosed.…

Outcome: PO provided education and training to Medical Support Assistants in the Prime clinic.

Issue: Computer equipment is issued to blind Veterans who are followed by the Visual Impairment Services Team (VIST). The Durham VA Medical Center requested a VACO Office of Blind Rehabilitation site visit in June 2012 to review concerns with management of…

Outcome: Processes are being changed to prevent this.'

Issue: Patient A received a letter intended for Patient B. The letter included full name, last four digits of the SSN, address and appointment date and time. Veteran A mailed letter back to VA. Update: 11/29/12:Patient B will be sent a…

Outcome: The responsible service counseled both employees who work in that particular clinic and assigned additional training through TMS. We placed a report of contact in their file for the remaining of the fiscal year.…

Issue: Two prescription bags for Veteran A were dispensed correctly at the same time, but Veteran A left one of his bags in the medication pass through. The bag contained a non-controlled medication. Veteran B picked up his medications after Veteran…

Outcome: Pharmacy staff was also reminded on to confirm with patient that they received all medications, and checking to ensure the all medications are removed from the medication pass through window prior to assisting the next patient.