VA New England Healthcare System (VISN 1)

Issue: On August 25, 2011 I opened an email from Chief Patient Services to notify me that an appointment letter for Veteran B. that was sent to along with Veteran As. Update: 08/25/11:Veteran A will be sent a letter of notificaiton.…

Outcome: Notification letter sent and provided education to the responsible service.

Issue: QM sent me a incident report that was among other things needing to be scanned in to records. Report states that on 8/8/11 Veteran A recived prescription of Veteran B. Report states that the medication was mailed from Providence. Veterans…

Outcome: Notification letter sent. Educated Pharmacy Clerk.…

Issue: The ISO generated a sensitive patient record report that revealed employee A had accessed employee B's record. The report was sent to the supervisor for review of appropriateness. The incident is currently being investigated by the Supervisor. Update: 08/18/11:The employee…

Outcome: Access was removed on 8/18/11 while an investigation is being done on this employee to see why they access the other employees records. The appropriate action will be taken by HR and Supervisor.…

Issue: Veteran A came to the clinic for lab work. He had the envelope with the appointment papers in it. He did not have his own lab slips. He had the labs slips for Veteran B. The lab slips contained Veteran…

Outcome: Credit Monitoring provided - service educated on importance of double checking paperwork prior to sending.…

Issue: A Rights Management (RMS) protected email was accidentally sent to a non-VA email address along with other VA employee email addresses. The email included the Veteran's name, full SSN and protected health information. Update: 08/15/11:The email went to an outside…

Outcome: The employee was educated to review email addresses sent utilizing the RMS system as it may be accessed via the non VA e-mail system even though it is protected.

Issue: The information for Veteran B was included with Veteran A's information. This information was from FEE basis and it included the authorization. Update: 07/28/11:Veteran B will be sent a letter offering credit protection services.…

Outcome: Education was given to employee on the importance of verifying information on patient before sealing envelopes to mail.

Issue: The report states that on 06/08/11, Veteran A received Veteran Bs prescription. The Veterans have the same last name. The report states that the medication was mailed from Providence. Actions, Progress and Resolution Date: The information disclosed contained Veteran B's…

Outcome: Notification letter sent. Employee required to retake privacy training.…

Issue: A researcher lost an informed consent document that included full name, full SSN, and medical information. Update: 07/25/11:The Veteran will be sent a letter offering credit protection services.NOTE: There were a total of 22 Mis-Handling incidents this reporting period. Because…

Outcome: PO states the researcher was re-educated on the importance of protecting PHI/PII. Primary Investigator (PI) has files in a locked room in a locked cabinet. This NSOC ticket was for the following- a research investigator was found to have lost…

Issue: A health insurance form was mailed to a VA Fee Basis provider. It contained personally identifiable information (PII) and protected health information (PHI) including the Veteran's name, address, date of birth and full SSN. It was mailed to the wrong…

Outcome: PO completed investigation into the incident and discovered that employee in the Fee Basis unit mistakenly mailed letter and corresponding claims forms- which include patient name, full SSN, DOB, etc. to non-VA outside party. There are two individuals impacted by…

Issue: An incorrect copy of medical records were mailed to an outside attorney. The attorney reported the error. The records were secured by the receiving party and are being mailed back to the medical records Supervisor at the facility. Once received…

Outcome: HIMS Supervisors were advised that employee needed re-education regarding appropriate verification and validation procedures. Notification letter has been sent and a redacted copy is attached.