VA New England Healthcare System (VISN 1)

Issue: Incorrect lab orders were given to the wrong Veteran. Correct information was faxed directly to the lab after event occurred. Incorrect orders were recovered. Unable to determine which Medical Services Assistant (MSA) gave the incorrect orders to the Veteran. Education…

Outcome: Education provided at staff meeting.

Issue: Release of Information (ROI) staff was requested to process a release of medical information to a VA employee/patient, per a valid authorization. The ROI staff left the report, unprotected, on employee/patients desk where it was visible to anyone in the…

Outcome: Employee retook training and was counseled by Privacy and supervisor regarding appropriate protection of sensitive information.

Issue: The facility recieved complaint that a letter arrived to Veteran A in an unsealed envelope, possibly exposing the Veteran's full SSN and medical information. Update: 12/02/11:Veteran A will receive a letter offering credit protection services.…

Outcome: Privacy officer met with area and gave them a glue stick to seal envelopes or required them to use more tape to secure the envelopes.

Issue: Medical Records belonging to Veteran A were mailed to Veteran B. When received by Veteran B, they contacted the facility immediately that it was not their information. Update: 11/29/11:Veteran A will be sent a letter offering credit protection services due…

Outcome: Re-training File room Staff on how to ensure that records go to the correct requestor. Shipping envelope will be addressed on the outside prior to leaving the File room and being sent to the Mailroom. Currently the process is to…

Issue: A letter addressed to Veteran A was recieved by Veteran B. Veteran B mailed the letter to the Privacy Officer. The letter is in VA control. Update: 11/21/11:Veteran A will be sent a letter offering credit protection services, because the…

Outcome: Administrative Officer for Primary Care alerted of the issue and education for desk staff provided.

Issue: Veteran A's information was mailed to Veteran B on 06/20/11. Today, 11/04/11, Veteran B returned them to the VAMC File Room. The documents contained Veteran A's name, last four digits of the SSN, date of birth and protected health information…

Outcome: Employee was educated as to his error. Records were retrieved. Credit monitoring letter was mailed to Veteran.…

Issue: Veteran A was mailed a copy of his pre-surgical instruction form and Veteran B's information was inappropriately stapled to it. Veteran B's information that was inappropriately disclosed included his name, address, full SSN, date of birth and diagnosis. Update: 11/02/11:Due…

Outcome: Associate Nurse Manager and Supervisor will reinforce the privacy policy and training in the administrative area where the information was mishandled. Employee that mishandled this information was identified and counseled with recommendation to re take privacy and awareness training.…

Issue: A provider dictated a report about Veteran A but used Veteran B's SSN; the dictated report ended up in Veteran B's record. Veteran B was told he had a diagnosis but he did not because it was Veteran A's information…

Outcome: The HIPAA Notification Letter has been mailed to the Veteran. Education was given to the provider on usage of correct way to dictate and the importance of verifying correct information.…

Issue: A bill for Veteran A was sent to Veteran B. Veteran B returned the original bill to the Health Resource Center upon receipt. Update: 10/25/11:Veteran A will be sent a notification letter due to name and PHI being exposed.…

Outcome: Notification letter sent and correct address has been verified.

Issue: Medical records were disclosed to another Veteran with the same first and last name, different middle name. Veteran A who received wrong information hand delivered records to Veteran B whom the records actually belonged to. Update: 10/18/11:Due to full SSN…

Outcome: PO states incorrect lab requisition form was mailed to the wrong patient. Patient who received the discharge instructions returned them to Togus. They were mailed to the correct patient. Employee who performed the error was notified and apologized. Notified to…