VA New England Healthcare System (VISN 1)

Issue: Veteran A was seen in the Urgent Care Clinic in December and was handed a copy of Veteran B's discharge instructions. The patient returned the paperwork to the Privacy Officer. The discharge instructions contained Veteran B's name, full SSN and…

Outcome: Education was given to staff on check to make sure that they are handing the correct information to patient.

Issue: This ticket is being placed to address a complaint filed with the Office for Civil Rights (OCR 11-127758). The complaint by a family member alleges that they were given another Patient B's information along with their family member's information. The…

Outcome: Notification letter sent out to patinet on February 2, 2012.

Issue: Veteran A requested his archived medical records. The records were copied and sent to Veteran A. When Veteran A reviewed them he realized he had Veteran B's documents in his records. He came back to the Release of Information (ROI)…

Outcome: Educated ROI clerks that when pulling hard copy files from the Archives we need to be more diligent in reviewing documents prior to making a release.Documents that were found in this Veterans record is being refilled in the correct Archived…

Issue: Veteran A was given Veteran B's information when leaving the Primary Care clinic area. Veteran A realized this when he got home and immediately called the VA to return it. He put it in the mail today. Update: 01/24/12:Veteran B…

Outcome: Privacy Officer discussed incident with AO for Primary Care, ACS Clinic Coordinator, Primary Care Nurse Manager, and Firm Chief of Primary Care. Responsible individual could not be identified. PO reviewed incident and provided guidance at an All Staff Primary Care…

Issue: Veteran A was mailed Veteran B's blood work results. Veteran A's fianc reported the incident to the Privacy Officer (PO). The PO requested that documents be mailed back to hospital. The PO sent out a return envelope to Veteran A's…

Outcome: PO spoke with both Nurse Supervisor and PC Chief regarding the incident. PC Chief noted that lab tests results should be mailed using the template in CPRS, which automatically captures veterans address. Using this will help prevent another transcription error…

Issue: Veteran A called the Call Center to let them know that he received another Veteran's medication in error. The Veteran B address was entered with Veteran's A address. Veteran A was told to destroy the pills because they could not…

Outcome: Education was given to employee on updating patient address information

Issue: Veteran A contacted the Bangor CBOC stating he received a letter with lab results and a diagnosis on Veteran B. Veteran A was notified to mail the letter back to the VA for proper disposal. Veteran B will be notified…

Outcome: Education provided to staff at CBOC's.

Issue: Veteran A was sent home with a lab slip for a stool sample with Veteran B's name and full SSN on it. Update: 03/02/12:Veteran B will receive a letter offering credit protection services.NOTE: There were a total of # Mis-Handling…

Outcome: Education was given o the employee on verifying information before handing to patient.

Issue: A Veteran employee requested a copy of who accessed his medical electronic records. Once he received the list he questioned the access of four employees on the list. The Privacy Officer (PO) will investigate the reason for these employee accessing…

Outcome: The Privacy Officer talked with all employees on the importance of not going into an employee's records without have the authority to do so. The PO asked if all employees have taken their Privacy training. The PO also talked with…

Issue: VA Credentialing staff noticed on January 18th, that a box containing approximately 5 credentialing files that were supposed to go into the secure shredding bin was empty. Update: 01/20/12:It is believed that the files were thrown out with the regular…

Outcome: Notification letters sent to 6 employees. Possible contributing factors to this incident included: a) a new Housekeeping employee was assigned to the area and may have unintentionally emptied the box into the regular trash; b) Credentialing staff mistakenly believed that…