VA Mid South Healthcare Network (VISN 9)

Issue: A Veteran called the Privacy Officer to report that while he was an inpatient in September 2011, he stated he informed staff that the only person they were to release any information about him being an inpatient, is his niece…

Outcome: HIPAA Notification letter to be mailed to Veteran on 12/5 and is uploaded as an attachment. This incident occurred back in September 2011, so the PO could not determine who actually failed to offer this Veteran his Opt In/Out rights…

Issue: The Privacy Officer (PO) was informed this morning that a VA employee has been taking prescriptions of Veterans and having them filled at outside pharmacies by acting as these Veterans' Caregiver. These Veterans were sent out to other pain clinics…

Outcome: The employee who acted as Veteran's caregiver in order to get their prescriptions has resigned. Before the time that this employee resigned, their access was immediately pulled. Notification letter has been mailed to Veteran. Investigation is ongoing with outside authorities.

Issue: When searching some lockers that had been retrieved from storage, our Chief Logistics and others found patient listings in one of the lockers. The locker had been stored at an offsite facility that is shared by the VA facility &…

Outcome: Unable to determine who might have left these lists in the lockers; SOPs are being developed to ensure furniture is searched prior to being removed from the facility.

Issue: A routine Sensitive Patient Access Report (SPAR) indicated a potential unauthorized access to deceased Veteran employee's medical record. This affected 1 deceased Veteran. Data elements include full SSN, home address, home phone, and protected health information (PHI). The investigation is…

Outcome: Recommended Administrative Action and all employees re-take privacy training. I have already conducted focused privacy training with these employees.…

Issue: Seven merit promotion folders that contained approximately 75 employee/potential employee applications were left unattended in an outside hallway for more than 72 hours. All records have been recovered. The data types involved include full name, full SSN, home address, home…

Outcome: Reminded employees appropriate PHI safeguards.

Issue: Somehow, two patients were mistakenly placed in the same exam room. When the physician entered the room, he assumed that Patient B was a family member and began discussing the health information of Patient A. Patient B became upset (he…

Outcome: Staff reminded to be more cautious when placing patients in the exam rooms. It appears that this was due to inexperienced staff members placing patients in the exam rooms. Unable to identify the patient whose information was being discussed in…

Issue: The Pharmacy notified the Privacy Officer that a bag of medication for Patient A actually contained the medications for Patient B. Patient A picked up the bag, found the error & returned everything to the pharmacy. Update: 11/04/11:Veteran B will…

Outcome: Staff reminded to be more cautious when packaging medications.

Issue: On 11/01/11, a Veteran/Employee (who is a social worker at the Nashville campus and receives treatment there as well) obtained a copy of a Sensitive Patient Access Report (SPAR) from the Privacy Officer (PO) for the period of 05/01/09 through…

Outcome: 11/30/11 - Upon investigation, PO could not justify two employees' accession of the records. PO referred f/u concerning appropriate disciplinary action to the Service Chief/HR.PO mailed CM letter to Veteran/Employee. PO requests closure of the ticket.…

Issue: Two patients are on the same medication The first dose has to be administered by our staff. The nurse accidentally gave Patient A the medication belonging to Patient B and vice versa. The remaining medicine was then sent home with…

Outcome: Staff reminded to be more cautious when administering medication.

Issue: Patient A was given Patient B's medication and reported the incident to the Pharmacy. Patient B's name, address and type of medication was compromised. Update: 11/01/11:Patient B will be sent a notification letter due to full name and protected health…

Outcome: Staff were reminded to be more cautious when packaging/dispensing medications.