VA New England Healthcare System (VISN 1)

Issue: Veteran A received Veteran B's appointment notification along with his own. Update: 06/22/11:Veteran B will be sent a notification letter, due to name and PHI being exposed.…

Outcome: Notification letter sent to Veteran B....this was a Pitney Bowes mail sorter issue. Inserted two letters in one envelope.…

Issue: VA Clerical Staff printed lab orders and handed to a Veteran. The lab order printed however was for the wrong Patient. The lab orders were given to Quest diagnostics. The error was discovered by the VA lab manager upon looking…

Outcome: Employee who made the error was re-educated on privacy issues.

Issue: A Physician printed out eye clinic notes for 4 Patients and took them to the bathroom located directly across from the main entrance to the Operating room which is in the publicly accessible area of the floor. He mistakenly left…

Outcome: The physician self reported and understands potential consequences.

Issue: A patient requested copies of his labs and they were mailed to the wrong Veteran. The labs included the patient's name, address, full SSN and lab results. Update: 04/27/11:The patient will receive a letter offering credit protection services.…

Outcome: Supervisor of employees were retrained on the importance of making sure that the information sent is mailed to the correct Veteran.

Issue: Employee A attempted to access her Electronic Official Personnel Folder (eOPF) for the first time using log-in information provided to her. When she got in, she noticed the SSN and first name (of Employee B) did not belong to her.…

Outcome: sent employee credit monitoring letter. Please close ticket…

Issue: Community Based Outpatient Clinic (CBOC) notified the Privacy Officer (PO) that six patient appointment cancellation letters were misfaxed to a residence. It did not include full SSNs or dates of birth, but did include other medical information. Update: 05/23/11:All four…

Outcome: PO will require Sender CBOC Firm V Manager retake the VHA Web Based Privacy training. Sent letters of Notification to each Veteran…

Issue: During a criminal investigation of a stolen supervisor/employee record from one of our CBOC's, it was established that the local AFGE had received a folder of documents from one of our staff member\xe2\x80\x99s spouse. This folder contained documents of differing…

Outcome: The Union President and the Employee Relations Specialist were provided training and awareness from both the ISO and The PO on their responsibilities when and individual attempts to submit PHI for Union or HR evidence files. They have both agreed…

Issue: A printout of the first page of the Patient Inquiry for Veteran A was mailed to Veteran B. Veteran B mailed the page back to the Privacy Officer. The Patient Inquiry contained Veteran A's name, full SSN, data of birth…

Outcome: Staff reminded to carefully review what is pulled off of printer and put in envelopes to patients.

Issue: The National Guard requested Patient A's information with a valid patient release form. An audiology report for Patient B was inadvertently sent with it. Patient A received Patient B's full SSN, full name, and medical information. Update: 05/13/11:Patient B will…

Outcome: staff was made aware.

Issue: Clinician mistakenly sent copy of a daily appointment listing home with a patient in his pile of documents. Documents has been returned and no abuse of information suspected. Update: 05/12/11:The appointment list did not contain any clinic names or healthcare…

Outcome: Clinician immediately retrieved the document from the party, re-took the privacy and information security training and also implemented workflow changes to prevent this incident from re-occurring. Credit monitoring letters have been sent to all impacted individuals.