VA Midwest Health Care Network (VISN 23)

Issue: Veteran A reported to the VA he received Veteran B's appointment letter in the mail with his. The appointment letter for Veteran B included Two scheduled appointment names/times; Veterans name, address and last four. Veteran A returned the letter to…

Outcome: Email sent to volunteer supervisor to provide education again.

Issue: Research gave Veteran another Veteran's medication. The other Veteran returned the medication to the VA unopened. Update: 05/21/12:Veteran B will be sent a notification letter.…

Outcome: Research staff was educated on importance of patient privacy and giving out correct meds.

Issue: Veteran A received Veteran B's patient notification letter regarding his anticoagulation appointment. Information on letter included name, address, and Protected Health Information (PHI). Update: 05/17/12:Veteran B will be sent a letter of notification.…

Outcome: I spoke with the Support Services staff and the supervisor will now be stuffing these envelopes instead of the voluntary service workers.

Issue: Veteran A received Veteran B's patient notification letter regarding his anticoagulation appointment. Information on letter included name, address and Protected Health Information (PHI).There were two incidents of this. Veteran B's identity is only known for one of these instances. Update:…

Outcome: I spoke with the Support Services staff and the supervisor will now be stuffing these envelopes instead of the voluntary service workers.

Issue: Employee A inappropriately accessed another Employee B's Veteran Electronic Health record eight times between February 6, 2012 and May 3, 2012. Another employee overheard her conversation regarding the employee's medical condition. Update: 05/16/12:Employee B will be sent a letter offering…

Outcome: Case referred to HRMS for action.

Issue: A letter was sent to the wrong Veteran which contained a Veteran's full name, address, labs, and medications. Update: 05/15/12:One Veteran will be sent a letter of notification.…

Outcome: Staff in department was educated on importance of patient privacy and disclosing information to the appropriate person.

Issue: A Veteran received a mental health Compensation and Pension (C&P) examination consult on another Veteran in the mail. He has had it for a few months and just returned it. It took him so long to return because he was…

Outcome: Brought to employees attention the importance of patient privacy and ensure we are sending information out to the correct person and double checking.

Issue: Human Resources sent the Union a letter regarding the diagnosis of an employee they were representing. The letter stated why they were let go of their job due to not being able to perform the job duties due to the…

Outcome: The Union did not request the document be sent to them nor did the Veteran request that it be sent to them. PO have communicated with the HR Chief regarding this incident and asked that she educated all staff.…

Issue: Health technician from the St. Cloud facility lost patient appointment list in a public hallway. It was recovered by a VA employee. Update: 05/14/12:Four (4) Patients will be sent letters offering credit protection services.…

Outcome: Working with St. Cloud facility; Employee required to retake Privacy Training.

Issue: A Veteran received an advance directive packet of blank forms and it had another Veterans medication list in the envelope. The veteran reported this to Privacy Officer (PO). Update: 05/14/12:Veteran B will be sent a notification letter.…

Outcome: Completed QA check on other Advance Directive packets.