VA Midwest Health Care Network (VISN 23)

Issue: A lab technician went to draw blood from a Veteran for a test. Veteran had just been discharged. Lab label was dropped on the way back to lab. Lab tech discovered when returned and re-traced steps. Later, a VA employee…

Outcome: Employee has been counseled by his supervisor.

Issue: Veteran A received Veteran B's prescription through the mail from the our local facility. Veteran A reported the incident to the Pharmacy and will be returning the medication to the facility. The Pharmacy will enter an incident report. Veteran B's…

Outcome: The employee who sent the item (prescription) to the incorrect Veteran was educated about the need to double-check before sending any medications out in the mail. The employee stated she understood and realized her error. The Veterans had the same…

Issue: Veteran A received Veteran B's appointment reminder letter with Veteran B's name, address, and last four digits of the SSN. Update: 10/25/12:Veteran B will be sent a notification letter.…

Outcome: This issue was brought to the attention of the mailroom clerk to be aware of this event, and strive to prevent this from happening again.

Issue: A VA employee mailed a patient's records to the wrong law firm. The law firm reported this and returned the records. The records contained the patients name, address, full SSN, date of birth and protected health information (PHI). Update: 10/17/12:The…

Outcome: To HR for action, also employee required to re-take privacy training.

Issue: Veteran A reported receiving Veteran B's medical records in the mail with theirs. The information contained lab results, full name, full social security number. Veteran A returned all records to the VA Privacy Officer. Update: 10/16/12:Veteran B will be sent…

Outcome: Incorrect documents were deleted from Vista Imaging. Education was given to all scanning staff regarding importance of checking correct patient and consequences of errors.

Issue: An employee placed the wrong label (Name, SSN, and DOB) on an envelope and mailed it. The USPS returned it for no good address. Update: 10/15/12:The Veteran will be offered credit protection services.…

Outcome: Supervisor conducted education with all CBOC staff.

Issue: Veteran A received a Rating Decision letter from VBA which contained Veteran B's name, address, full SSN and details of the Veterans service-connected medical condition. Veteran A sent the documents to the Privacy Officer once he realized the documents belong…

Outcome: Other federal agency was contacted and advised that they had mailed information beloning to Veteran A to Veteran B. Advised them to send out information to Veteran A again to ensure Veteran had the appropriate information. Veteran A was offered…

Issue: A Veteran's wife submitted a complaint through a Senator's Office voicing HIPAA violations within the medical center. The Veteran previously submitted a complaint, and the Privacy Officer (PO) followed up. The Dialysis unit is a large open area with little…

Outcome: 1) All patients will sign a release of information before labs/notes are given to patient or forward them to Release of Information to process2) Patients will be asked up front if they would like to discuss treatment in a separate…

Issue: A release of Information (ROI) employee sent all medical records of a patient to the wrong fax number. The fax number listed on the law firm's letterhead was incorrect. Update: 09/26/12:An internal unencrypted e-mail was sent. No data breach has…

Outcome: ROI staff notified law firm they had the wrong fax number on their letterhead. ROI mailed information request to requestor. No violation found by VA staff.…

Issue: Veteran A reported receiving two other Veterans' information in with his own via mail. The information included a progress note which contained Veteran B's full name, full social security number, diagnosis, medications etc. The second included Veteran C's lab results,…

Outcome: Supervisor to speak with employees to address issue and educate.