VA Mid South Healthcare Network (VISN 9)

Issue: Patient A received Patient B's letter from the VAMC. It contained 7332 information. The data involved in the letter was Full Name, Last Name, Home Address. It was outside of VA control for more than 72 hours. Update: 10/07/11:Veteran B…

Outcome: Provided Privacy re-education for service that sent out the letter.

Issue: Privacy Officer's (PO's) became involved with this incident on 9/28/11. A string of encrypted Outlook emails was forwarded the PO's to investigate a possible privacy breach of an employee/Veteran's CPRS Record. On or about 9/21/11 - It had been reported…

Outcome: PO determined some accesses to this record were inappropriate. PO personally provided additional training to both the employees from the Business Office that were involved with this incident, as well as all of Social Work Service as it relates to…

Issue: On 10/01/11, Veteran A contacted the Privacy Officer (PO) at the Nashville campus to report the following:For two years, Veteran A stated he has received correspondence, appointment reminders (via phone), and medications belonging to Veteran B. Veteran B stated he…

Outcome: 10/17/11 - Incident due to human error. Appropriate training was provided to the employee with emphasis on the importance of identifying the correct patient when obtaining information.…

Issue: Patient A received Patient B's appointment letter. It was double stuffed. The PHI included Full Name, Last 4 of SSN, address and name of clinic. The information was on one patient and out of VA control for > 72 hours.…

Outcome: Training was not provided... However, we modified the routing slip to reduce the sensitivity and amount of PHI on the form.

Issue: On 09/28/11, Veteran A presented to the Outpatient Pharmacy (Nashville Campus) to retrieve his five medications and was also dispensed two medications which belonged to Veteran B. The error was noted later in the day when Veteran B presented to…

Outcome: UPS envelope containing the meds given to wrong Veteran have been returned to the pharmacy and destroyed. The pharmacy tech did not follow correct procedure for obtaining proper ID before dispensing the medication. Employee was counseling regarding the importance of…

Issue: Veteran A received a Catastrophically Disabled Veteran Enrollment Approval Request Form belonging to him. However, he also received the same type of application for Veteran B. The form contained Veteran B's name, date of birth and full SSN. Update: 09/28/11:Due…

Outcome: PO was unable to determine who the employee was that actually mailed this document in error. PO went to the Clinic that it is suspected of where this was mailed from and provided education to the employees about always double…

Issue: Veteran A requested his records through Release of Information (ROI). He received his records today and indicated that he also had the records of Veteran B. In researching this issue, it was found that outside medical records on Veteran B…

Outcome: The document in the wrong chart was deleted and placed in the correct chart. HIMS chief spoke parties involved. Education was provided with regard to QM processes around the scanning processes. Credit monitoring was provided to the Veteran who's records…

Issue: Veteran A requested copies of medical records. Upon receiving those medical records, he also received copies of another Veteran's records. The Veteran called and reported receiving the wrong records. We are arranging return of the records. Update: 09/23/11:Veteran B will…

Outcome: CM Letter to be mailed on 9/28/11. The employee involved with this incident will receive a written counseling in addition, has received education and training on how to avoid a reoccurrence from these type incidents.…

Issue: On the morning of 09/21/11 around 7:30 AM, a VA RN staff member discovered that her personal locker located at the Hematology & Oncology outpatient ward had been broken into. She examined the items in the locker and noted that…

Outcome: Credit monitoring letters have been mailed to the affected VA staff and her spouse. This case is considered closed as of 10/4/2011. Staff has been advised not to keep personal records containing sensitive information in the lockers, especially for overnight.…

Issue: Veteran A requested a copy of his medical records from the Release of Information (ROI) office. When Veteran A received the copy of the records in the mail, he discovered Veteran B's records were also included with his records. Veteran…

Outcome: CM Letter signed and to be mailed on 9/26/11. The employee involved with this incident will receive a written counseling and will also be provided training/education to eliminate this occurrence from happening in the future.…