VA Mid-Atlantic Health Care Network (VISN 6)

Issue: A Provider left telephonic information about lab results on a telephone message system concerning lab report of Veteran. The Veteran lives with his sister who played back the message and became aware of brother's lab report. The caused disharmony in…

Outcome: The DBCT agreed to accept the meetings with the provider and the PO as an alternate means of notification. Written notification is not required.Referred to service chief for administrative action.…

Issue: Veteran A received the lab results for three other Veterans in the mail. Update: 06/04/12:The three Veterans will receive a HIPAA notification letter.…

Outcome: Privacy Officer conducted education and Training with HAS/MSA staff in Prime Two clinic regarding the standard operating procedures when handling PHI. Privacy Officer will monitor compliance.…

Issue: Veteran A received Veteran B's medical records through release of information in error. Update: 05/24/12:Veteran B will be sent a letter offering credit protection services.…

Outcome: The responsible service is taking disciplinary action.

Issue: Veteran A received Veteran B's medication by mail. Names were very similar and address was changed for incorrect Veteran. Update: 05/17/12:Veteran B will be sent a letter of notification.…

Outcome: Responsible employee, supervisor and chief were notified and encouraged to be more careful in the future when entering changes. The first and last names in this case were exactly the same.…

Issue: The Privacy Officer received a call from a Veteran who had been mailed another Veteran's test results with specific diagnosis. Both Veterans have the same first and last name with a different middle initial. Update: 05/16/12:Veteran B will be sent…

Outcome: Staff mistakenly mailed Veteran's information to another Veteran with the same name. Still implemented measures to verify correct patient when multiple patients have the same name.…

Issue: Veteran A was sent Veteran B's medical records in error by the Release of Information office. The information was returned to VA. Veteran B's Name, address, full SSN, date of birth and protected health information (PHI) was compromised. Update: 05/16/12:Veteran…

Outcome: Documents returned to VA, Supervisor of ROI clerk re-educated staff on ROI checklist process to include proper identification of requestor.

Issue: Veteran A received Veteran B's medical progress notes by error through the release of information office. Update: 05/15/12:Veteran B will be sent a letter offering credit protection services due to full name and SSN being disclosed.…

Outcome: The service responsible for the error is taking disciplinary action.

Issue: Durham Employee A contacted United Services Automobile Association (USAA) concerning a potential loan. Employee A was notified by USAA that she was listed as the co-signer on a loan that was in default. She was further notified that the primary…

Outcome: The matter has been referred to Hospital Administration to take the appropriate disciplinary action.

Issue: Veteran A received medication information sheet in the mail for Veteran B. Update: 05/04/12:Veteran B will be sent a notification letter.…

Outcome: Acting Pharmacy Chief provided education to all Pharmacy staff to avoid further incidents of this type.

Issue: This incident was referred by VA Police. A complainant states that another employee may have accessed his medical records without authorization or need. Update: 05/01/12: Investigation. The possible improper access to his medical records by another employee in violation of…

Outcome: Two subjects to receive administrative action. Documents sent to service chief.