VA Midwest Health Care Network (VISN 23)

Issue: Employee mailed records to the wrong Patient. The information contained Patient B's full SSN, full name, medical information, date of birth, and home address. Update: 12/04/12:Patient B will be sent a letter offering credit protection services due to full name…

Outcome: To HRMS. Also employee required to re-take privacy training.

Issue: Veteran A contacted the Privacy Officer (PO) to report that he received an envelope in the mail containing a Progress Note detailing a recent visit he had with his provider. However, Veteran A discovered an additional sheet of paper in…

Outcome: Employees have deleted email and also deleted from their deleted items.

Issue: Veteran A reported receiving Veteran B's lab testing kit in the mail. The label on the test included Veteran B's first and last name and full social security number. Veteran A returned the lab kit over to the VA. Update:…

Outcome: Education with staff and started a two person check process to ensure this does not happen again.

Issue: Past 5 months of medical records that we sent to the patient never made it to his home address and can not be found. Update: 11/13/12:The Patient will be sent a letter offering credit protection services.…

Outcome: No Violation on VA's part.

Issue: A health tech's significant other whom she lives with called the clinic in which she works to make an appointment. The health tech took the call and should have went into appointment scheduling in VistA to schedule the appointment, however…

Outcome: To HRMS - Probationary employee.

Issue: A VA Employee found a 3x5 index card in a VA stairwell containing the name, full Social Security Number, Date of Birth and medical notes,. Indications are the information did not leave the facility. The card was turned over to…

Outcome: Retrieval. Unable to determine where or who it came from.

Issue: VA Patient A was sent an incorrectly labeled medication bottle with the correct medication. The label on the bottle was for another VA patient. The label contained the name and last 4 of Veteran B. Update: 11/13/12:Veteran B will receive…

Outcome: Education to employees by supervisor.

Issue: A VA Police Employee recently met with their local VA Provider. After the evaluation, the VA Provider contacted VA Employee Health to tell them the Veteran/employee was a danger to self and others with access to a firearm based on…

Outcome: The treating provider attached their progress note to the wrong consult, which was an Employee Health consult. Employee Health received an alert, read the note, and then notified HR. Employee Health should have notified the patient they would be talking…

Issue: A Veteran accidently grabbed the appointment list with his records at the front desk. He returned the list to the VA. Update: According to the Privacy Officer, the appointment statistics list that stated the patients full name, full SS# and…

Outcome: Lists were returned by the Veteran. Staff in Comp. & Pen. have been notified to not leave patient information sitting on the front desk and to safeguard those documents.

Issue: Patient Effects employee self-reported a missing document that contained the name and last four digits of a Veterans SSN. She was unable to find the document when she needed to retrieve it for filing. She was unsure if she had…

Outcome: I was determined that we could print a label that contains all the information needed and the SSN could easily be cut off. The staff were educated and informed of this change. All were in agreement that this would be…