VA Mid South Healthcare Network (VISN 9)

Issue: Veteran A called the VA Chattanooga Outpatient Clinic to report that when he was at the VA Chattanooga Outpatient Clinic on Friday, January 11, 2013, he was provided various paperwork when leaving. When he got home, he then found he…

Outcome: It was determined this incident was caused by a human error, in that the Nurse failed to perform a check of the documents, prior to providing to Veteran A.Nurse Manager was notified and the individual nurse involved will be provided…

Issue: Patient A notified us that the records that he received from Release of Information (ROI) contained a note that belonged to Patient B. When the privacy Officer (PO) looked into it, she discovered that this note had been scanned into…

Outcome: Scanning & ROI have been reminded of the need for caution when handling documents with PII.

Issue: A VA TVHS employee who works at the VA Chattanooga Outpatient Clinic reported to her Service Chief that she suspects another VA employee may have accessed her personal information from the VA computer system. The Service Chief contacted the Privacy…

Outcome: Corrective Actions still pending at Privacy Office and Executive management. 1/23/13 - With this access being determined as inappropriate access, this access issue was referred to the Business Office for appropriate action. Business Office is currently working with HR to…

Issue: The Privacy Officer found an "Administrative Officer of the Day Report" lying on the ground beside the recycle bin, in front of Building 3. The report is dated medical information sent to local hospital, one item is regarding patient arrangements…

Outcome: I discussed with the Assistant Chief Business Office; the issue has been discussed with the responsible employee. Education has been provided to all employees to ensure proper safeguarding of our Veteran's information.…

Issue: Veteran received consent form 10-5345 with instructions mailed by Consolidated Patient Account Center (CPAC) located at this facility. After receiving the information, he realized that the information printed on the back of two separate pages was billing information for two…

Outcome: Credit Monitoring letters were mailed Wednesday January 9th The issue was discussed with the responsible employee as well as the supervisor. Education was provided to all employees in the service.…

Issue: At the end of an appointment, a resident wrote the patient's follow up information on the clinic listing and gave it to the patient to turn in to the clerk. This should have been written on the patient's router. The…

Outcome: PO attending followed up with resident regarding facility's privacy policy.

Issue: A bag of medications was mislabeled and sent to the wrong patient. There are two patients with the same name (except for middle intitial). He is to return the bag & contents during his appointment next week. Update: 12/26/12:One patient…

Outcome: Staff reminded to be more cautious when handling documents with PII/PHI.

Issue: Patient A had entered a temporary address; the change was made to Patient B's profile. Patient A received a bag of medication that was intended for Patient B. Patient A is to mail medications and packaging to the Pharmacy. Update:…

Outcome: Employees reminded to verify identity prior to making changes in patients' profiles.

Issue: Patient A received a reminder letter for his own appointment and a second letter intended for a Patient B. The Privacy Officer (PO) is unsure if these letters still have the last four digits of the SSN on them. The…

Outcome: Employees reminded to be more cautious when handling documents with PII/PHI.

Issue: Chief, HIMS found a sheet of labels in the Cafeteria on the floor. These labels had 1 patient's information on it. Some of the labels were missing and we assume that these were already placed on paperwork, chart, etc. However,…

Outcome: Credit monitoring letter mailed. PO will be addressing this issue through staff education as well as a bulletin to remind staff not to caring information with them without ensuring that it is safeguarded at all times.…