VA Mid-Atlantic Health Care Network (VISN 6)

Issue: A Veteran Center employee requested sensitive record review. It was noted that the Veterans Center Office Manager has accessed the Veteran/Employee's information 5 times. This is the second reported case. Update: 09/20/12:One Veteran will be sent a letter offering credit…

Outcome: Attached please find the credit monitoring letter for the Veteran. The employees that accessed the record had access revoked. The final actions for the employees was handled by the Vet Center's Privacy Officer and our local HR.…

Issue: On September 5, 2012 a mental health (MIRECC) research assistant brought to the attention of the Primary Investigator (PI) that a consent form for one patient was missing. Both the patient and the pharmacy had copies but the original could…

Outcome: The Primary Investigator and his team have been instructed to retake the Privacy training to raise their level of awareness in the protection of our Veteran's privacy. Certificates submitted to the Privacy Office.…

Issue: Veteran A's appointment list was mailed to Veteran B. This appointment list contained a full name, SSN and a date and time of a clinic appointment. Veteran B sent back the list to the sender. Update: 09/12/12:Veteran B will be…

Outcome: Offer of Credit Monitoring letter sent to affected Veteran. Employee responsible for mis-mailing was counseled to be more careful.…

Issue: Veteran "A" was faxed Veteran "B's" medical records. The medical records were intended to be faxed to another facility. A staff member dialed the wrong fax number. Update: 09/07/12:Due to full SSN and medical information being exposed, Veteran B will…

Outcome: Letter sent 9/24/12, the employee has be educated on properly faxing with the use of VHA Directive 6210, Automated Information System Security. to Verify the fax number prior to sending the fax and, in order to prevent misdialing, Ensure that…

Issue: Veteran A received a letter addressed to Veteran B. Veteran A called the clinic and is returning the letter that belongs to Veteran B. The letter contained Veteran B's name, address, partial SSN and diagnosis. Update: 08/17/12:Veteran B will receive…

Outcome: The clinic manager has notified all employees to print to the correct printer.

Issue: Veteran A was in the process of being discharged when he found a blood label on the window seat with Veteran B's full name and full social security number. Veteran A returned the blood label to VA police. The label…

Outcome: Credit monitoring letter has been sent by PO. Staff were reminded to protect these labels at all times and to discard them appropriately if they find them abandoned.

Issue: Veteran A's wife viewed images on a CD as provided by VA. The images contained Veteran B's full SSN, date of birth, full name, and date of report. The report also contained imaging results. Veteran A's wife returned the CD…

Outcome: The responsible service is planning to remove the image from Veteran A's medical record. Also, they are planning to address the issue from a systems perspective by writing a standard operating procedure when these incidents are noticed before they are…

Issue: Veteran A had a hearing test in the Audiology Clinic on 08/01/12. He asked for a printed copy of his hearing test. The Audiologist accidentally gave him Veteran B's printed hearing test. This has Veteran B's full name, and full…

Outcome: PO have discussed this incident with the responsible employees. Privacy education has been provided. The immediate supervisors have been notified. The Nurse Executive and the Chief of Health Administration Services (HAS) have also been notified. Appropriate action by the supervisors…

Issue: Veteran A received package from VA containing medical records. The Veteran previously provided medical records from the private sector to VA for informational purposes. A VA employee packaged the records and returned them to the Veteran in an envelope. The…

Outcome: Responsible service identified the responsible employee and provided education. The employee also repeated the privacy training.…

Issue: Following a group study/research session on 07/19/12, one of the study participants, Veteran A inadvertently picked up the attendance sheet with his handouts when leaving the group meeting. The attendance sheet is kept on a table where the research staff…

Outcome: The Research group will continue to use a sign in sheet for each group, however the patients study ID number will be removed. One sheet will be used for each group. After the patients sign in for the session staff…