VA Mid South Healthcare Network (VISN 9)

Issue: A Tissue/Cytology Request for Patient A was mailed along with letter to Patient B. Patient B was instructed to destroy the information. The request included Patient A's name, full, SSN and protected health information (PHI). Update: 01/06/12:Patient A will receive…

Outcome: Re-educated staff and created procedures so this wouldn't happen again.

Issue: Per the Report of Contact (ROC) supplied by the Chaplain today: "I came into station on Saturday afternoon, 12/24/11 expecting to find my log book on the computer desk in the library located in the chaplain's office. Both library door…

Outcome: Intern was terminated from training program. All Chaplain Service personnel received additional inservicing on protecting PHI and PII data; prohibition on use of log books, note books and other written/hardcopy records; and specific guidance on prompt and proper disposal of…

Issue: On 03/21/11, a VA Provider created a Primary Care Progress Note during a scheduled visit for Veteran A, however the Progress Note was entered into the wrong CPRS Record of Veteran B. This entry error was not noticed until Veteran…

Outcome: CM Letter was mailed to the affected Veteran on 1/4/12. Privacy Officer has made arrangement with the other Veteran to return to document in question on his next visit to the VA. Privacy Officer spoke with the Provider who entered…

Issue: On 12/12/11, Pharmacy Service received a telephone call from Veteran A who was reporting that he noticed he received medications for Veteran B in the mail. Once Pharmacy Service researched, it was determined that on 12/2/11, VA Tennessee Valley Health…

Outcome: It was determined it was an employee error occurred when preparing the medication for shipment. PO has certified the employee involved has been educated and re-trained on the importance of accuracy when prepping medications for shipment. Veteran A has returned…

Issue: VA Eemployee A discovered the time sheet of Employee B had been incorrectly queued to her printer and reported this incident. The Privacy Officer (PO) attempted to determine who may have printed this document in error, but could not determine.…

Outcome: The PO attempted to determine who printed this document or the area it could have been queued from and was unsuccessful. IRM does not have the ability to determine where information was queued from. Routine messages are sent to all…

Issue: A VA clerk was faxing information to the Social Security Administration (SSA). He verified the fax number with the SSA but, when he faxed the information, it went to a utility company. At this time, the Privacy Officer (PO) is…

Outcome: Employee stated he had verified the number with SSA; reminded to verify & use caution when dialing FAX number

Issue: The Information Security Officer (ISO) received a call from Bank of America in Tampa, Florida regarding a box received 12/13/11 (but opened 12/14/11) that was addressed to Bank of America which contained files of Patient Records. The Information Security Officer…

Outcome: Clerks completed UPS shipping training. Also, stored addresses were removed from the system so they would have to be typed in each time, hopefully avoiding similar situation in the future.…

Issue: Veteran A received Veteran Bs prescriptions and paperwork in his own bag with his prescriptions and paperwork from the Outpatient Pharmacy. Veteran A returned the medication and paperwork to the Outpatient Pharmacy on the same day. The paperwork and prescription…

Outcome: Staff reminded of the need for caution when preparing medications for delivery.

Issue: An individual who was applying to volunteer was taken to Human Resources (HR) for fingerprinting. He was escorted by a volunteer. When he reached HR, it was discovered that he was not only carrying his paperwork but also had the…

Outcome: Employees in area responsible reminded that documents must be protected.

Issue: A Release of Information clerk mailed out requested information to the incorrect Veteran. The Veterans had the same name, only one was a Jr. The Jr. (Veteran A) requested the records but the Veteran that was not a Jr. (Veteran…

Outcome: ROI Supervisor has provided training to this employee who inadvertently disclosed information. ROI Supervisor has also placed disclosure alerts on these records since there are three patient's with the same name, which caused this inadvertent disclosure. Credit monitoring has been…