VA New England Healthcare System (VISN 1)

Issue: VA police contacted the Privacy Officer (PO) to let him know they forwarded him a patient's Veteran Identification Card (VIC) they had received in the mail. The PO contacted Veteran A, the owner of said card, and he stated that…

Outcome: Employee had to retake privacy training. Credit Monitoring letter sent 5/16/11

Issue: Chaplain intern went into CPRS to look up his father's diagnosis. Update: 05/05/11:The Veteran will be sent a notification letter.…

Outcome: Computer access was removed - training was redone.

Issue: Patient A had an appointment in Radiology. The check-in clerk checked in Patient A and then went to print out his wrist band. Unfortunately the clerk didn't select the new patient button and printed out the previous patient's wrist band…

Outcome: Instructions were given to verify patient name with looking at the wrist band.

Issue: Veteran A was sent a full copy of his medical record. The paper chart contained non-VA medical records for Veteran B. The records for Veteran B contained his name, date of birth and protected health information. This information was released…

Outcome: The Privacy Officer developed a process for the ROI staff to review 100% of paper documents prior to copying paper records. This will prevent this error from being repeated. The file room staff was also provided with training to ensuer…

Issue: Prescription and medication lists and supplies for two patients were found in a dumpster located outside a local store.. Documents and materials are still being recovered and investigated further by VA Staff. The documents contained the patients' name, full SSN…

Outcome: The following is what is currently being provided for corrective action: 1. All HBPC nursing staff are being assigned the privacy and IS security training through LMS2. A locked cabinet will be provided to the HBPC nurses office in the…

Issue: Veteran A's data was printed on papers containing Veteran B's medical information. The information exposed included Veteran B's name, SSN, date of birth, and lab results. Update: 044/15/11:Veteran B will receive a letter offering credit protection services.…

Outcome: The Emergency Department administrative staff was immediately notified to cease copying the Means Test form to the reminder letter, as has been past practice. The Administrative Officer of the Day (AOD) staff was instructed to enclose the Financial Assessment form,…

Issue: A purchased care (fee basis) denial letter for Patient A was sent to Patient B along with Patient B's denial letter. The original letter was sent back to VA. Update: 04/12/11:Patient A will be sent a notification letter.…

Outcome: Staff and fee basis management were made aware.

Issue: The Associate Director for Patient Services/Nurse Executive contacted me to inform me that an employee in the Emergency Room accidentally had the wrong patient (Veteran A) sign his discharge paperwork. Veteran A got home and realized the had the wrong…

Outcome: Educated provider who made error. Retook the Privacy Web based training.…

Issue: A bill was sent to Veteran A from the Health Resource Center (HRC). The Veteran's address in VISTA is incorrect and belongs to Veteran B. Veteran B called the HRC to state the error and Veteran B returned the bill…

Outcome: The Patient Services Manager has been asked to change the erroneous address. Privacy is attempting to contact the Veteran via telephone. The Veteran does have an appointment at the CBOC and will be given the notification letter then.

Issue: Veteran A was given Veteran Bs information during his visit to the Primary Care clinic. He did not realize the error until he got home. It was unclear from his description what the documents (some kind of label), but he…

Outcome: Staff counseled to be careful when removing information from the printer and to make sure that it is being handed to the correct Veteran.