VA New England Healthcare System (VISN 1)

Issue: An employee called Veteran A to report his labs, only to be told that a consult request on Veteran B had mistakenly been mailed to his house this week. The request included Veteran B's SSN and address and medical information…

Outcome: Letter was mailed to Veteran; Education was provided to staff.

Issue: Veteran A went to pick up his records at the medical records section. He brought the records home and when he noticed he had Veteran B's record he shredded it in his personal shredder at his residence. The Privacy Officer…

Outcome: Documents were retrieved, verified and disposed of properly by the ISO on site. The Service Chief counseled the employee that mishandled the documents and then re-trained the entire section. PO completed credit monitoring letter and mailed it to the individual.…

Issue: The Pharmacy Chief provided an incident report that shows on 03/16/12, Veteran A received the prescription of Veteran B. Update: 03/20/12:Veteran B will be sent a notification letter due to name and Protected Health Information (PHI) being disclosed.…

Outcome: Employee was reshown the process to eliminate future errors.

Issue: It was discovered by the provider that a three page consult listing was part of Veteran B's packet but belonged to Veteran A. A's nursed notified the Privacy Officer (PO) that the provider took the three pages out and that…

Outcome: Employee was reshown the process to eliminate future errors. Notification letters sent to Veteran.…

Issue: Patient A was seen in a Clinic as Patient B and after the appointment went to travel and was paid as Patient B. Patient B was in the Clinic waiting to be seen and after two hours went to the…

Outcome: Travel Service paid the correct patient for travel to the clinic. The Doctor that saw the wrong patient reported this and placed an addendum in the note. The correct patient was also seen and a note placed. Patient safety was…

Issue: Veteran A stated that she had received the FEE basis letter for mammography and in her envelope was Veteran B's letter. Veteran A looked up Veteran B's information on white pages.com and contacted Veteran B and discovered Veteran B had…

Outcome: Employee was instructed on the proper procedures. Manager will also verify prior to signing off on the FEE paperwork. Notification letters sent to both Veterans involved.…

Issue: Several DD214s (Certificate of Release or Discharge from Active Duty) and fee dental approval letters were found in a file cabinet at a Recycling Center and reported to the VA Police. The files were transported by the employees of the…

Outcome: Staff conducted a review to verify that all stored furniture does not contain documentation of any kind. The review is complete and no other cases were located in the stored furniture areas. An SOP is being developed to create a…

Issue: Veteran received appointment letter for another Veteran which included his full name, address, date of birth and full SSN. Veteran immediately contacted Associate Director at VAMC. Pt Rep contacted this Veteran and he has sealed this letter and will deliver…

Outcome: Staff member who mailed information notified and counseled. Going forward, will review all patient information prior to mailings.…

Issue: A patient reported sending a certified mailing to the VA and gave the Privacy Officer (PO) the USPS certified number. The PO investigated and found that a VA employee signed for the mailing on 02/21/12 at 8:29 AM and brought…

Outcome: PO talked and e-mailed with the Mailroom Supervisor and the internal area Supervisor of the Service that sent the mail "back." All personnel in each area will be retrained to take extra care and investigative steps to assure that all…

Issue: School nurse called to report that a medication fax was sent to her school. It is unclear where the fax originated from. The Privacy Officer (PO) requested that documents be sent to facility. The information that was compromised was the…

Outcome: Clinic staff were provided with an incorrect fax number for the local private Hospital. As a follow-up, clinic employees were given guidance on providing reasonable safeguards for faxing information, i.e. verifying fax numbers prior to sending, using fax coversheet with…