VA Mid South Healthcare Network (VISN 9)

Issue: Paperwork belonging to Patient A's prescriptions was placed in Patient B's bag. Patient B notified the VAMC of the error and will return the paperwork tomorrow. The paperwork included Patient A's name and medication information. Update: 01/26/12:Patient A will be…

Outcome: Employee responsible reminded to use caution when handling documents with PII.

Issue: A local police officer had an appointment at our facility and became aggressive towards staff. The VA Police Chief contacted this officer's supervisor and informed him of the situation, including the fact that the Veteran was a patient here. There…

Outcome: VA Police will follow established procedure in the future when notifying non VA Police about individual's behavior while at this facility

Issue: A consult sheet was found in a public hallway by a VA Police Officer. We cannot determine who left the sheet unsecured. Information at risk was the Veteran's full SSN, full name and address, and medical information. Update: 01/23/12:Tjhe Veteran…

Outcome: Cannot be certain who left document unsecured but have reminded staff to be cautious when handling documents with PII.

Issue: Patient A notified the facility that he had received Patient B's medications when he picked up his own. Patient A is to return the medications, packaging, and documentation. Update: 01/19/12:Patient B will be sent a letter of notification.…

Outcome: Staff reminded of the need for caution when handling documents with PII/PHI.

Issue: On 01/10/12, Veteran A obtained copies of his medical records from Release of Information (ROI) at the Nashville Campus. Upon returning home, Veteran A realized he had also been given medical records which belonged to Veteran B. On 01/11/12, Veteran…

Outcome: 1/27/12 - Upon investigation, the Privacy Officer found the incident was due to a human error. On the day in question, there was one ROI clerk on duty and the volume of requests was enormous. Appropriate action has been taken…

Issue: A VA Patient (Veteran A) presented to triage wearing another Veteran's (Veteran B) armband, claiming it was an alias and initially refused to return it. VA Police recovered the armband. Veteran A refused to indicate how he acquired armband. The…

Outcome: Unable to determine if this was a facility error or patient issue. Staff reminded to use caution when applying armbands.…

Issue: A Medical Records Coder left a binder of coding reports outside of the admissions area around the smoking area. These reports covered the date ranges of 10/20/11 through 01/09/12. These reports had patients' full names, full SSN and discharge dates.…

Outcome: The PO suggested to the Coding Supervisor that she speak with all her coders and ensure that no one else is keeping this type of log. She recommended that the employee be educated on the policies and procedures that VA…

Issue: Veteran A called to notify us that he had received Veteran B's appointment listing. This listing would have had Veteran B's name, last four of his SSN and his mailing address as well as the appointment information. Update: 01/09/12:Veteran B…

Outcome: Staff reminded to use caution when handling documents with PII/PHI.

Issue: A Veteran was in the office of Social Work to complete an Advance Directive. The Social Worker laid the Veteran's papers on top of other documents belonging to 5 other Veterans. The Veteran unknowingly picked up all of the documents.…

Outcome: Credit monitoring letters signed and placed in the mail. Per Supervisor SWS: I verbally reminded the social worker of the importance of protecting Veteran information. She was very receptive to the education. I sent the attached e-mail to the entire…

Issue: A clerk prepared letters for two patients but, when putting them in the envelopes, reversed them. Patient A received Patient B's letter & vice versa. Information disclosed was full SSN, full name, and medical information. Update: 01/09/12:The two patients will…

Outcome: Clerk reminded to be more cautious when handling documents with PII.