VA Mid-Atlantic Health Care Network (VISN 6)

Issue: A VA employee sent a non-VA medical records and internal team message form to a Veteran. The packet of information included information for 6 different Veterans. The Veteran who received the information via mail returned the information back to VA.…

Outcome: Supervisor is recommending employee for discplinary action.

Issue: Employee who is a Veteran was admitted to the medical center for medical issues. Employee/Veteran requested an access report as he suspected co-workers viewed his medical record while he was hospitalized without authorization. Reviewed access report with employee/Veteran who reported…

Outcome: Both employees who accessed the employee/Veteran's medical record without permission were forwarded to HR for disciplinary action by the supervisor.

Issue: A VA employee sent a complaint to Joint Commission containing personally identifiable information (PII) and protected health information (PHI) along with a 7332 diagnosis. The Veterans are residents in the VAMC Community Living Center. The employee included the names of…

Outcome: Notification letters were signed and mailed 6/6/12. The employee was re-educated on release of information of 7332 protected information. A fact-finding was performed and provided to Human Resources service for appropriate corrective action regarding the inappropriate release.

Issue: On 04/17/12, the Privacy Officer recieved a call from a Social Worker at another VA hospital. The Social Woker stated that they were now treating a Veteran who had been seen at this facility and noticed records were released to…

Outcome: Process implemented to include identifying and underlining expiration date prior to scanning documents. This will assist staff in quickly identifying expiration date prior to release.…

Issue: The Privacy Officer (PO) received a call from Veteran A on 04/17/12, stating that his medical reports had been mailed to Veteran B. Veteran A stated that he had an appointment on 04/03/12. On about 04/12/12, Veteran A received a…

Outcome: Reiterated to staff that importance of protecting privacy of Veterans. Section supervisor will implement process to QA documents prior to being mailed to ensure envelope contains correct patient information.…

Issue: VA supervisor A mishandled VA employee B SF-52 form by leaving it unsecured in an unlocked room that is utilized by other employees. The form was found by VA employee C and returned to VA employee B. It is estimated…

Outcome: Education provided to all involved staff and encouraged them to share with their staff.

Issue: It was reported that a HIPAA Consent Research Document contained the Social Security Number (SSN) that was written on the participants form was the SSN of another participant in the study. The participant has been notified and is bringing his…

Outcome: The research staff member was re-educated on proper completion of the HIPAA Consent Research forms.

Issue: Veteran A received Veteran B's medication prescription by mail. Update: 04/05/12:Veteran B will be sent a letter of notification.…

Outcome: This occurred when the clerk put the package into the UPS system to generate a UPS overnight mailing label (patient names were very similar). The clerk has been educated and the need to double check all labels before affixing them…

Issue: During a fire drill on 3/27/2012, VA police noticed a broken wheelchair on the back loading dock of the VA Medical Center. An inpatient wristband was attached to the wheel and a medication sticker was stuck to the seat back.…

Outcome: Services involved in the incident have been educated to the importance of securing equipment with PHI attached.

Issue: The spouse of Veteran A called a Community Based Outpatient Clinic (CBOC) to notify VA staff that they had received a care plan in the mail that belonged to Veteran B. The spouse of Veteran A stated they were going…

Outcome: Reiterated to staff importance of verifying correct Veteran prior to mailing information. Staff put processes in place to verify information.…