VA Midwest Health Care Network (VISN 23)

Issue: Veteran A received his "next step in care" letter with Veteran B's letter attached to the back of his. He returned Veteran B's letter to the VA. The letter contained Veteran B's name and protected health information (PHI). Update: 01/21/13:Veteran…

Outcome: Staff educated regarding importance of patient privacy.

Issue: Clinical staff person used the wrong area code on a fax number. She inadvertently sent fax to a Data Storage Company who called and reported the mis-fax. They shredded the documents before we could retrieve. Update: 01/16/13:The Veteran whose information…

Outcome: Required to re-take privacy training.

Issue: A Veteran reported receiving a flu shot letter with another letter attached addressed to another Veteran. The letter contained Veteran B's full name and address. Update: 01/15/13:Veteran B will be sent a notification letter.…

Outcome: Had sensors checked on mail machine.

Issue: Veteran A was sent a hemocult slide test with Veteran B's information on a label from a VA employee. Veteran A called to report that the label did not contain their information but had another Veteran's information on it. Update:…

Outcome: Veteran A has returned the information he received that contained Veteran B's information. The lab worker who had given the Veteran the information was spoken with and was advised that in the future, when giving Veterans an item that contains…

Issue: A physician in a Minneapolis VA Healthcare System Clinic had seen by a patient. During the visit it was determined that a form was required to be completed. The physician left the room to obtain or to fill out the…

Outcome: Sent to contracting for letter of warning to be sent. Also, contract provider is required to retake Privacy and Information Security training.

Issue: VA employee reported that she provided patient information to the wrong health care facility. Update: 02/01/13:The Privacy Officer (PO) sent a letter to the Veteran notifying him that his name and purpose for visiting the hospital was shared with the…

Outcome: The disclosure was a mere mistake and the employee is aware of the need to make sure the right facility is called in the future. Remedial action was education provided to the employee.…

Issue: Patient A reported receiving Patient B's information in the mail on a research study. After further review, the employee identified four patient's information sent to an incorrect veteran through the mail. The information included the names, social security numbers and…

Outcome: Corrective action to prevent the incident from happening again:Mailing process will now be two stages:1) Assemble the mailing by research team member A2) Prior to sealing the mailing, research team member B will check to verify that the name on…

Issue: It was reported to the Privacy Officer (PO) that two people that were to have tele-medicine appointments in Bismarck, ND were placed in the same room instead of being place in their assigned rooms for their appointments. Investigation to fallow.…

Outcome: This massage was sent out to all participants Telehealth Program Privacy Protocols Service Line leadership please forward this email to all staff that are involved with Telehealth Video services. Last week there was a Veteran privacy violation that occurred. As…

Issue: Veteran A reported receiving a medication for Veteran B. The information on Veteran B included a name and medication. Veteran A reported the concern and returned the medication to the VA. Update: 12/13/12:Veteran B will be sent a letter of…

Outcome: Medication returned to the VA. The touch screen may beed recalibrated and the Pharmacicist did not match the label on the prescription bottle to the prescripion or patient information when checking the produc. All staff members involved had the correct…

Issue: A VA telework employee called a Veteran's family member to make them aware of his condition. Update: 01/02/12:The Veteran will receive a letter of notification.…

Outcome: The PO determined the employee did not have a reason to call the wife back. The employee was not informing her of information to benefit the Veteran. The employee's supervisor has been informed of the disclosure.…