VA Midwest Health Care Network (VISN 23)

Issue: A nurse disclosed a Veterans symptoms in the lobby around other Veterans. Update: 05/22/13:The Veteran will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Outcome: NA

Issue: An authorization was sent to a Veteran to sign but had another Veteran's information on it. The information at risk included the second Veteran's name, full SSN and diagnosis. Update: 04/25/13:One Veteran will be sent a letter offering credit protection…

Outcome: Employee re-educated. QA measure in place.

Issue: A Veteran reported he picked up two other Veterans' paperwork from the clinic. The paperwork contained names, clinic information and social security numbers on the forms. The Veteran destroyed the information via shredder after notifying the VA Update: 04/25/13:The two…

Outcome: Destruction of papers.

Issue: On 09/09/2010 a note was written by a social worker on the wrong patient. The patient whose record this note was located in requested a large date range of their records for a regional office claim and records including the…

Outcome: Note written on the wrong patient was removed from the incorrect chart and placed in the correct one. Author of note was educated on the importance of documenting on the correct patient.…

Issue: A clerk released a consult to a Veteran's insurance company for payment purposes but there was 7332 information in the consult and no authorization from the patient to release the 7332 information. Update: 04/22/13:Veteran A will be sent a letter…

Outcome: Clerk was educated and told to review every note for potential 7332 information prior to releasing. Letter was sent to the veteran explaining what occurred and his rights.…

Issue: An employee mailed a completed form to a patient and it had another Veteran's letter from a provider attached. Update: 04/16/13:The Veteran will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Outcome: Sent to HRMS for action. Employee required to re-take Privacy Training.

Issue: Veteran A's name and full SSN was on lab specimen container for Veteran B. It appears that Veteran B was not aware of the mistake as he brought back the specimen without mentioning it. The error was caught by a…

Outcome: Reminded Lab staff to double check all specimen containers for appropriate name.

Issue: Veteran B received a copy of a photograph that was taken during Veteran A's colonoscopy. Update: 04/05/13:The nurse did not clear the camera fully to set up for the next patient and when the system printed the photos, one of…

Outcome: New process has been implemented in the clinical care area in which employees must validate every identifier/photo on the sheet belong to the Veteran to whom the sheet of photos is being given.

Issue: A patient list/procedure note left out in public hallway in clinic. Update: 04/03/13:The list was left face up in the hallway for just over an hour. Letters offering credit protection services will be sent to 13 Veterans.…

Outcome: Addressed with clinic manager, re-educate clinical staff.

Issue: Pharmacy staff inadvertently gave a bottle of medications to Veteran A with the information sheet intended for Veteran B. The personally identifiable information (PII) included Veteran B's first and last name, address and the name of the medication. Update: 03/31/12:Veteran…

Outcome: Staff reminded to double check prior to handing out the medications.