VA Midwest Health Care Network (VISN 23)

Issue: The Research Office noticed that their research paperwork on one Veteran went missing. It was last seen in the Research Office in the basement, out of the file cabinet. It contained the consent form, inclusion/exclusion form, enrollment questionnaire, and the…

Outcome: The Research Supervisor educated staff on the importance of research records going back to the locked file as soon as they are finished working on them and ensuring they are filed in the correct area of the file.

Issue: A provider gave copies of records to Veteran A while in clinic. After Veteran A got home, he noticed the record belonged to Veteran B and called to report it. The records included Veteran B's full SSN, date of birth,…

Outcome: Re-take Privacy Training.

Issue: Fee Basis clerk accidentally sent Veteran A's Progress Note along with Veteran B's letter. When Veteran B opened the envelope and discovered that there was another Veteran's information that was sent to him in error, he contacted the facility and…

Outcome: The employee was counseled about not sending any patient PHI via Outlook as the employee does NOT have PKI. The employee had been previously cautioned by her supervisor not to share information in this manner. The employee stated they thought…

Issue: A VA employee entered a Computerized Patient Record System (CPRS) chart of a patient who was featured in the news media. This was not part of the employee's official VA duties. The employee entered the chart out of curiosity. Update:…

Outcome: To HRM for disciplinary action.

Issue: Veteran A reported receiving Veteran B's letter with the results from medical tests that were performed at the VA. The letter included Veteran B's full name, address and testing information. No 7332 information was included. Veteran A sent the information…

Outcome: Veteran returned the letter to the VA and privacy now has the original letter.

Issue: Release of information staff released a Veteran's (Veteran A) medical information and billing information to an insurance company without having a proper release form. We had a cancer claim form filled out by the insurance company and signed by the…

Outcome: Sent Veteran notification letter and educated staff.

Issue: Environmental Management Service (EMS) found a bag full of patient records including full SSN and protected health information (PHI) sitting in a trash bag liner in the hallway. They notified VA Police who contained the items in their investigative file.…

Outcome: Person responsible was found and educated/reprimanded. Credit monitoring letters sent out.

Issue: An EMS employee was in the cafeteria and found a packet of a patient's information/records folded sitting on the condiment bar. The employee gave this to their supervisor who in turn gave it to the PO. The PO contacted the…

Outcome: All nursing students were re-educated about this and the affiliate hospital was made aware of the incident.

Issue: Veteran A reported receiving Veteran B's letter with the results from medical tests that were performed at the VA. The letter included Veteran B's full name, address and testing information. No 7332 information included. Veteran A sent the information back…

Outcome: Documents were retrieved.

Issue: A check to the Webster County Veterans Affairs Commission was sent with a patients last name and first initial along wiht full ss#, date of service, amount paid, and CPT code. Update: 02/04/11:One Veteran will receive a letter offering credit…

Outcome: Webster County Veterans Affairs Commission is mailing back the check and inforrmation with it.Notification letters sent out.