VA Mid South Healthcare Network (VISN 9)

Issue: Veteran A received lab results and an x-ray report for Veteran B in the same envelope as his results. Veteran A's wife is a VA employee and brought the letter with Veteran B's information to the Privacy Officer this morning.…

Outcome: Employees and Volunteers were reminded to make sure that only the information that is for ONE Veteran be placed in the envelope prior to mailing. Notification letter mailed November 7th.…

Issue: Veteran A received Veteran B's medication in the mail. The protected health information (PHI) that was compromised included Veteran B's full name, last four digits of the SSN and date of birth. The Information was outside of VA control for…

Outcome: Staff was reminded to be more careful when handling PHI.

Issue: Veteran A called and reported that he was expecting a completed form to be mailed to his residence from the VA Hopkinsville KY CBOC. However, when he received something in the mail from the VA, the envelope contained the medical…

Outcome: CM ltr has been mailed to Veteran. The other Veteran has mailed the incorrect records he received back to the Clinic. The Nurse involved has been formally counseled and re-training was provided to the Nurse as well as all the…

Issue: Veteran A reported to the VA Chattanooga Outpatient Clinic to report that when he received his appointment lettter in the mail, apparently in the same envelope, was also the appointment letters of Veteran B.PO is waiting on the documents to…

Outcome: Mis-mailed appointment letters are in the possession of the PO. It was determined this incident was due to an equipment error, as appointment letters for two Veterans were placed in the same envelope. Employees involved with preparing letters for mailing…

Issue: Patient A Requested records from 2007 to present on 08/20/12. Veteran B requested records from 2005 to present on 07/20/12. Veteran A never received his records. Veteran B received his records along with Veteran A's records. Veteran B returned Veteran…

Outcome: Credit monitoring provided for Veteran. Letter mailed. MIS Chief discussing importance of checking records going in envelopes to ensure nothing of another Veteran is included.…

Issue: A Veteran/Employee made a formal complaint that she felt her record was inappropriately accessed. Ran a SPAR report and determined there was access fo the record. Investigation is going to be conducted. Information involved is the entire medical record and…

Outcome: Employee was required to complete Privacy training and administrative action was taken.

Issue: On 10/31/12, the Privacy Officer (PO), Nashville Campus, was notified of the following: On 10/30/12, while writing a courtesy violation in the parking garage (Nashville Campus), the VA Police Officer observed a computer print-out with patient information, located in the…

Outcome: 11/13/12 - Provide has been re-educated on the importance of safeguarding patient information. CM letter mailed.…

Issue: Several prescriptions meant for Patient A were mistakenly included in the package that was given to Patient B. Update: 10/31/12:Veteran A will be sent a notification letter, as his name, address, and medications were disclosed.…

Outcome: Staff reminded of the need for caution when handling medications for dispensing.

Issue: On October 19, 2012, Veteran A, while at the VA Chattanooga Outpatient Clinic, received a print-out of his appointment profile. When he got home, he discovered on the back of his appointment profile was a consultation sheet belonging to Veteran…

Outcome: CM letter prepared and mailed on 11/5/12.It was determined the Nurse involved in this incident is no longer employed by the VA. However, the Chief Medical Officer and Nurse Manager of this VA CBOC Clinic will provide education and a…

Issue: Chief, Medical Officer, Charlotte Avenue, contacted the Privacy Officer, Nashville Campus, regarding the following:Today, a provider, Charlotte Avenue CBOC, inadvertently gave Veteran A a narcotic prescription which belonged to Veteran B. The provider discovered the error and notified pharmacy to…

Outcome: Upon inquiry, the PO found the employee did not perform a quality check on the prescription for accuracy before giving to the Veteran. Employee has been re-educated to eliminate a recurrence.…