VA Midwest Health Care Network (VISN 23)

Issue: A Veteran left a copy of his medical record in the lobby. Release of Information staff collected it and called him to pick it up. Update: 12/23/11:Records were left by the Veteran himself. This is not the fault of VA.12/28/11:Further…

Outcome: Patient stated that he never left these records in our lobby. I show that we faxed them to the base hospital. I am working with the base HIPAA staff to see if any of their staff would have been in…

Issue: VA Employee A was on break and left items from their employee mailbox inside of a magazine in the patient waiting area. VA Employee B discovered mailbox items inside of the reading material and delivered to the Privacy Officer to…

Outcome: VA Employee A was found to be negligent in leaving PHI in patient waiting area within reading materials. Employee A was counseled on importance of safeguarding protected information and protected health information. Memo of events findings were sent to Employee…

Issue: An LPN lost a folder with 7 Narcotic Renewal Consults between clinics. These were found by a VA employee within 15 minutes of being lost. The documents contained the patients' name, address, date of birth, and full SSN. Update: 12/14/11:Seven…

Outcome: Education was provided to the employee regarding protecting Veterans' information.

Issue: A message was received from an employee at Sanford Education Center with the information that a packet of seven pages of medical information regarding a Veteran had been faxed to the Sanford Education Center in error. The correct recipient was…

Outcome: The employee who sent this fax in error is no longer employed at this facility.…

Issue: A Veteran received a letter and along with it was someone else's medication list. The Veteran mailed the incorrect document back to the VA. Update: 12/05/11:The individual whose medication list was disclosed will receive a letter of notification.…

Outcome: Education was given to staff regarding the importance of privacy and attention to detail when mailing things out.

Issue: The Post Office sent a search request form that stated one of the envelopes of medical records we sent to a third party requestor was torn open and lost. Update: 11/28/11:The Veteran will be sent a letter offering credit protection…

Outcome: No corrective action taken as it was out of VA control.

Issue: A resident from an affiliate hospital had a logbook stolen out of his vehicle at the affiliate hospital. This logbook contained information on all patients he has seen in the Omaha VAMC Operating Room (OR) for the past 20 months,…

Outcome: The resident received additional training regarding protecting personally identifiable information (PII) and protected health information (PHI).

Issue: A Dental claim denial letter was sent to the wrong Veteran. The Veteran Service Organization (VSO) employee reported it to the VBA employee who sent letter and information to the VHA Privacy Officer. The denial letter included the Veterans name,…

Outcome: Staff member was provided direction to double check all mailings to make sure each item is for the addressed patient on the envelope.

Issue: A VA employee reported papers containing 57 Veterans' names, dates of births, full SSNs along with personal tax information and a social security card was missing from a secure clinical call center. The VA Police were contacted and an investigation…

Outcome: A high priority work order was placed to have the call center rekeyed. Only employees who work in the area and supervisor will have a key to this room. All protected health information (PHI) will be locked up overnight.

Issue: Veteran A's paperwork was placed in Veteran B's mailed medication package. Paperwork included Veteran's name, address, medicine, and directions for use. Update: 10/31/11:Veteran A will be sent a notification letter.…

Outcome: PO talked to receiving Veteran's POA who said he did not see any information in the package received. He reported that the package had been thrown away.…