VA Mid South Healthcare Network (VISN 9)

Issue: Employee A's documents were scanned into Employee B's eOPF. Employee B discovered the documents & turned them in. Update: 02/10/11:Employee A will receive a letter offering credit protection services since their full SSN was exposed.…

Outcome: It is unlikely that this error was caused at our facility as most of the scanning of personnel records was done offsite.

Issue: An employee reported for work and noticed a document on the fax machine. When reviewing the document, it was determined it was a report from a private doctors offices concerning another employees work restrictions. The employee that found the document,…

Outcome: Staff involved with this incident have been informed to insure a secure fax is used in the future and also provided advice of scanning information and sending via PKI encrypted email to avoid the possibility of employee information being seen…

Issue: Pt A picked up Rx; when he opened, he discovered it actually should have gone to Pt. B Update: 01/31/11:Patient B will be sent a letter of notification.…

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

Issue: Patient A received her own records that she had requested. Patient B's records were also included. The PO is not certain what records were disclosed nor who was responsible. Patient A is to return the records to the PO. Update:…

Outcome: Responsible employee reminded to use caution when handling documents with PII/PHI

Issue: During an audit of the study entitled: "Memphis VAMC: Nutrition Day 2010 in the United States," the Memphis VAMC Research Compliance Officer noted that informed consent for 9 study subjects were not obtained, i.e. Principal Investigator did not take the…

Outcome: PO met with Principal Investigator (PI) to explain the risk and financial cost of this breach in terms of credit monitoring, etc. PI has learned her lessons from this breach and has assured PO of her willingness to prevent such…

Issue: On 1/20/11, Patient A was seen in the Nashville VA ER secondary to a motor vehicle accident.On Sunday, 1/23/11, an EMS employee approached a CWT worker (who is Patient A's former roommate) and reported Patient A was treated in ER…

Outcome: CWT worker was counseled regarding the importance of protecting PHI. 3/3/11 - Sent email to VA IRCT with redacted ltr. PO requests closure.…

Issue: A patient received another patient's account statement in the envelope along with his own. Update: 01/24/11:The patient will be sent a letter of notification.…

Outcome: Not caused by our staff

Issue: A Veteran had an appointment at one of our CBOC's on 1/10/11. At the end of that appointment, he was given a Medication Reconciliation Note by A nurse. He did not review this document until this past weekend and at…

Outcome: The employee invovled with this incident was re-trained and provided education on double checking documents with ID of Veteran.

Issue: A VA employee mis-faxed a Prosthetic Form to an incorrect fax number. The receiver notified the facility of this issue and provided the documents received. Update: 01/07/11:Veteran will receive a letter of notifciation.…

Outcome: Education and training to include being aware of and double checking the fax number prior to sending, was provided to the employee that was involved with this mis-faxed document.