VA New England Healthcare System (VISN 1)

Issue: During the transportation of a nursing home patient to an appointment at another facility, the patient's paperwork flew out the open window of the vehicle when the vehicle hit some bumps in the road. The paperwork included the patient's name,…

Outcome: Privacy Officer followed-up with Nurse Supervisor and employee (Patient Escort) was counseled on the importance of securing patient information using either a HIPAA envelop or locked pouch. Nurse Supervisor e-mailed all CSAs and Nurse Managers regarding using the HIPAA envelopes…

Issue: A VA employee reported today that he inadvertently gave Patient Bs appointment letter to Patient A. The employee printed out an informational packet for Patient A and didnt realize that Patient Bs appointment letter was within the contents. Patient A…

Outcome: Credit monitoring letters sent, see attachment, Employees educated.

Issue: The lab results for two (2) VA Patients were mailed to the wrong patient. Information disclosed was full name, full SSN, DOB, lab results, and address. Update: 02/23/12:Two (2) Veterans will be sent letters offering credit protection services.…

Outcome: Issue has been referred to supervisor and HR for further action.

Issue: An employee's Payroll deduction for Labor Organization Dues was mistakenly faxed to a outside person with an employees information to have dues taken out of their pay check. The person called the employee to inform them that she received her…

Outcome: Incident is being referred to HR for action.

Issue: A Veteran requested a copy of the Sensitive Patient Access Report (SPAR) that shows who accessed his Electronic Medical Record (EMR). His Supervisor accessed the employee/Veteran's appointment managment system with the employee right there to verify the dates of his…

Outcome: The Chief of Staff is Counseling the employee and will forward documentation to the Privacy Officer.

Issue: A VA clerk in the Release of Information (ROI) office handed information to Veteran A that contained a progress note for Veteran B. The information contained Veteran B's name, address, full SSN and protected health information (PHI). Update: 02/10/12:Veteran B…

Outcome: Issue is being addressed by Human Resources.

Issue: An employee felt that the Employee Health nurse had given out a diagnosis to his supervisor without his permission. He was being fitted for the N95 PPE Mask and was not able to clear. He was however cleared for the…

Outcome: After investigation, it was found that the nurse did in fact reveal a diagnosis with the employee's supervisor and knows that she should not have done this at all. Her supervisor is being informed of this incident and will take…

Issue: Veteran A requested information and received Veteran B's information with it. The Veteran A contacted Veteran B and then Veteran B contacted the VA. Veteran A received Veteran B's full name, full SSN, and lab results. Update: 02/07/12:Veteran B will…

Outcome: Education was provided to the clinicians to send requests for medical information to the release of information department.

Issue: A VA patient's daughter reported that her dad was handed 20 pages of information upon discharge. When she got home, she realized that 1 page belonged to another Veteran. The document contained the Veterans name, full SSN, and diagnosis. Update:…

Outcome: Educated area - consults will be printed on a printer that will eliminate this error. Staff reminded to check all pages before handing discharge info. to patients.…

Issue: Veteran A, who is the father of Veteran B, received his son's medications in the mail. Someone changed the son's address to the father's address. They have the same names. The father informed the son and will get the medications…

Outcome: Education to employees about making sure the correct address in patient records.