VA Midwest Health Care Network (VISN 23)

Issue: The Information Security Officers (ISO) were looking through the Sensitive Patient Access Report and came across an employee accessing a Veteran/employee's chart. The ISO gave the report to the Privacy Officer (PO). The PO will follow up with the employee…

Outcome: Employee received a one day suspension.

Issue: Veteran A received Veteran B's medication in the mail. The information disclosed includes Veteran B's name and type of medication. Update: 08/30/11:Veteran B will receive a letter of notification.NOTE: There were a total of 90 Mis-Mailed incidents this reporting period.…

Outcome: Pharmacy is working on a plan to decrease the number of mis-mailed prescriptions.

Issue: A Doctor left his clipboard with a couple appointment lists on it in the hallway on a ledge by the elevators. These lists included 42 patients' full names, full SSNs, phone numbers, co-pay status, lab time, and x-ray time. While…

Outcome: Education was given to physician by the PO on the importance of protecting our patients privacy. Credit monitoring was already sent out and uploaded.…

Issue: Three employees accessed other employees' charts or allowed the other employee access under their account. Update: 08/08/11:The three (3) Employees will be sent letters offering credit protection services, as their full names, full SSNs, and DoBs were accessed inappropriately.…

Outcome: Evidence folders have been submitted to HRMS. Required to retake privacy training as well.

Issue: Veteran A received an envelope intended for Veteran B at his address. Veteran A stated he did not note the name on the envelope was not his until after he realized the contents of the envelope belonged to Veteran B.…

Outcome: The employee who sent the envelope of lab work to the Veteran was identified and the PO met with the employee to discuss the ramifications of this situation. The employee expressed an understanding of the seriousness of the issue and…

Issue: A letter containing Veteran A's name, address and ultrasound information was sent to Veteran B. Veteran B called into the community Based Outpatient Clinic (CBOC) and has returned the lett Update: 07/19/11:Veteran B will receive a notification letter.08/03/11:The Privacy Officer…

Outcome: PO provide educational training to the employee. PO updated the information on this ticket to state that the patients DOB and Full SS# was in fact on it.…

Issue: A consultation sheet concerning one patient was mis-faxed to a private business that is not in any way related to health care, and has no reason to receive any protected health information. The fax contained the patient's name, full SSN,…

Outcome: This was an isolated error; employee reminded to verify proper fax number before sending all faxes in the future.

Issue: Patient A was given Patient B's appointment letter by a VA employee. This included Patient A's name and address only. Patient A is sending back the letter that was meant for Patient B. Update: NA…

Outcome: Education given to staff on the importance of patient privacy.

Issue: Veteran A brought in a prescription for Veteran B that was mailed to him inappropriately. Veteran B's name and type of medication was compromised. Update: 06/30/11:Veteran B will be sent a notification letter.…

Outcome: Notification letter sent and the Pharmacy is updating processes and procedures to ensure a repeat is unlikely to reoccur.

Issue: Veteran A's medications were sent to Veteran B. Veteran A's name and type of medication were compromised. Update: 06/30/11:Veteran B will be sent a notification letter.…

Outcome: Notification letter sent and the Pharmacy is updating processes and procedures to ensure a repeat is unlikely to reoccur.