VA Midwest Health Care Network (VISN 23)

Issue: The Environmental Management Service (EMS) cleaning staff found a 1 inch Compensation and Pension (C&P) file sitting in the lobby. There was no one around it. The EMS staff turned it into the eligibility staff who contacted the Privacy Officer…

Outcome: All staff in the area were questioned and importance of patient privacy and safeguarding sensitive information was presented.. The last person to remember having it was the C&P physician who thought he put it back on the file in the…

Issue: Veteran A was handed a copy of Veteran B's x-ray report in the emergency department. After he got home he noticed it was not his, called to report it, and mailed it back to the Privacy Officer (PO). The x-ray…

Outcome: Education with all staff in ED.

Issue: A letter was mailed to Patient A. The letter contained Patient B and Patient C's appointment information. The letter has not been received by the Privacy Officer (PO), it is en route from Patient Advocate. Update: 09/13/12:Veteran B and C…

Outcome: Staff educated about importance of reviewing all information in letters.

Issue: A VA Provider sent a notification letter and pathology report to the wrong patient with the same first initial of the last name and last four digits of the SSN. The name, address full SSN and medical information was compromised.…

Outcome: The note was removed from the other Veteran's medical record. The notification letter and results were placed in the correct Veteran's record by the author of the note.…

Issue: Veteran A came to his clinic appointment and brought a white plastic mailing envelope with his name on it with label stating VAMC Lincoln, NE 68510-2451. Inside this envelope were refill medication paper for accu-check plus a test strips for…

Outcome: Staff was educated on the importance of disclosing information to the appropriate Veteran.

Issue: A VA employee placed a medication label (full name, full SSN, and date of birth) on a package that was sent out in the U.S. Mail. Update: 09/04/12:The patient will receive a letter offering credit protection services.…

Outcome: Staff was made aware of the need to place envelopes for Pharmacy in different bins than mail to be sent to the UPS.

Issue: A VA nurse left a detailed voice message on a patient/Veteran's phone, reading a progress note to include describing patient's behavior. Patient/Veteran's family heard the voice message and the diagnosis. Update: 02/27/13:The Veteran will receive a HIPAA letter of notification.…

Outcome: education was completed with employee

Issue: A VA employee found paperwork on one Veteran laying on the ground outside of the VA facility. The VA employee picked up the paperwork and returned it to the Privacy Officer. The paperwork was probably laying outside less than 3…

Outcome: Eductation provided by the Chief of Medicine to Residents.

Issue: A VA Employee accessed a Veteran's health record without a business related reason for doing so. Update: 07/24/12:The Veteran will be sent a letter offering credit protection services due to name and full SSN being accessed inappropriately.…

Outcome: Sent to HR for action. Required to re-take privacy training.

Issue: Veteran A reports an employee in a clinic gave him a copy of Veteran B's lab report. The report contained Veteran B's name, full SSN and medical information. Update: 06/29/12: Veteran B will receive a letter offering credit protection services.…

Outcome: Provided education with all MSA in clinic regarding QA check prior to providing patient med list for appointment.