VA Mid-Atlantic Health Care Network (VISN 6)

Issue: An SF-50 form, Notification of Personnel Action, was posted on the public drive in a file that had employee's last name in it. This file could be opened by any VA employee. This SF-50 contained the Beckley VAMC Director's full…

Outcome: I have talked with our CIO and asked her if something can be done to prevent single documents from being saved directly to the Public Drive without being deposited into a specific folder (that's what happened in this case). I…

Issue: Upon discharge from the medical center, a fee basis authorization note for Veteran A was attached to Veteran B's discharge paperwork. Veteran B's wife reported the incident. At this time, it is not known how the fee basis authorization was…

Outcome: The responsible service has made arrangements to place signs in printer areas reminding staff to check documents before printing and mailing. Also, they plan to remind all staff at the monthly meeting.…

Issue: Under FOIA, a VA employee requested the successful applicant's "name, present and past position titles and occupational series, present and past grades, present and past annual salary rates (including performance awards or bonuses, incentive awards, merit pay amount, meritorious or…

Outcome: The Privacy Officer will now use the Adobe Acrobat 9 pro software to redact FOIA requested documents.

Issue: Veteran received another Veterans medication and medication information sheet. The medication sheet contained the Veteran's name and address. Update: 07/13/12:Veteran B will be sent a notification letter.…

Outcome: Acting Pharmacy Chief and Privacy Officer will conduct a mandatory meeting to resolve the noted trends in handling of PII and PHI within the Pharmacy Service. Privacy Officer will emphasize the importance maintaining the veteran's privacy and the handling of…

Issue: A Staff member incorrectly scanned a Portable Do Not Attempt Resuscitation (DNR), for Veteran A into Veteran Bs record and mailed the original form to Veteran B. The staff member realized they scanned the DNR in the wrong record when…

Outcome: Credit monitoring letter mailed on 7/24/12, staff member re-trained on scanning and mailing of Veteran/patient forms.

Issue: Veteran A received the appointment profile for Veteran B in the mail with her lab results. The appointment profile contained Veteran B's name, address, date of birth, full SSN and appointment information. Update: 07/06/12:Veteran B will receive a letter offering…

Outcome: Supervisor responsible for the clinic reminded staff to review paperwork before mailing. Also, they are looking into a separate printer in which to print patient letters to avoid this error in the future.…

Issue: A Veteran gave the Privacy Officer a mismailed lab letter he received with his information. Update: 07/05/12:One Veteran will be sent a letter of notification.…

Outcome: Privacy Officer provided training to the Prime Clinic responsible for the disclosure. Mail Directive 6609 reviewed with staff. Privacy Officer will conduct training with the entire service at the next Quarterly staff meeting to ensure compliance with the Facility Privacy…

Issue: A VA volunteer returned a drivers license to the wrong person. The drivers license contains the person's name, address and date of birth. Update: 07/03/12:Veteran B will be sent a letter offering credit protection services.…

Outcome: Volunteer received additional training and case was returned to service chief for administrative action.

Issue: Veteran A received a medication information sheet attached to his medication that belonged to Veteran B. The medication information sheet included Veteran B's name and medication information. Update: 06/26/12:Veteran B will be sent a notification letter.…

Outcome: Privacy Officer and Acting Chief of Pharmacy provided education and counseling to the pharmacist who processed the Veteran's prescription. Pharmacist will take proactive measure maintain compliance with the Facility's Privacy policy.

Issue: A Pharmacy employee sent Veterans A's prescription to Veteran B. The information that was compromised included Veteran A's name, and medication information. Update: 06/18/12:Veteran A will be sent a notification letter,NOTE: There were a total of 23 Mis-Mailed incidents this…

Outcome: Employee referred to service chief for admnistrative action.