VA New England Healthcare System (VISN 1)

Issue: Four nursing medications lists were returned to the ward by a Veteran who was discharged two weeks ago. The documents were in his discharge paperwork. Update: 02/11/13:Due to full SSN and medical information, four (4) Veterans will be sent letters…

Outcome: The employee responsible was counseled by her supervisor and this breach should not be repeated.

Issue: A Veteran was left a message on his phone about his request for medication. There was too much detail on this information left for his wife to listen to. Update: 03/01/13:The Veteran will be sent a HIPAA notification letter.…

Outcome: Re-educated on the importance of not leaving too much information on a answering machine.

Issue: A Psychiatry Resident had his/her car broken into off campus and his/her backpack was stolen. In the backpack the resident had CPRS chart print-outs of 3-5 patients which included fill name, full social, diagnosis, and other personal information. They also…

Outcome: Action is being taken with the resident. Education is being provided to residents as a whole.…

Issue: Veteran A was inadvertently given Veteran B's discharge diagnosis and medication name and dosage. The Physician realized the mishap and called Veteran A, who received the information. Veteran A was instructed to shred the information. The Chief Emergency Room Physician…

Outcome: The Physician was advised to be more careful.

Issue: An appointment reminder was mailed to incorrect Veteran. The appointment reminder letter was mailed back and returned to the Privacy Officer (PO). Update: 01/31/13:One Veteran will be sent a letter offering credit protection services due to full name and SSN…

Outcome: Education provided.

Issue: A provider informed the Privacy Officer (PO) that a form that he completed for a Veteran had disappeared. He had hand carried it to the Release of Information (ROI) department and they were not there, so he left it with…

Outcome: A new process was put in place so that this issue will not happen again.

Issue: CT results from Primary Care were mailed to the wrong Veteran. The Veteran receiving incorrect results mailed back to the Privacy Officer (PO). Update: 01/31/13:One Veteran will be sent a letter offering credit protection services due to full name and…

Outcome: PO notified Primary Care of their error. They then mailed the results to the correct patient and provided education in their dept to staff members. Credit monitoring letter was sent to veteran.…

Issue: A health technician was checking in a Veteran for his visit and was given his medicare cards to be scanned into the computer and the Veteran was called by the physician to be seen and the health technician told Veteran…

Outcome: The patient private insurance identification card and Medicare identification card has been retrieved and returned. The health technician was educated on the issue of not repeating this procedure again and was told to please return all personal information back to…

Issue: Employee requested sensitive patient access report as he believes a colleague was in his medical record. Update: 05/15/13:There was an inappropriate access, though it is not clear if the employee requested the other employee to access the record or not.…

Outcome: Strongly recommended that Employee work within her official scope of duties; access medical records on a need-to-know and minimum necessary basis; and re-direct any colleagues (who are VA Employees/VA patients and who work in the same area or work closely…

Issue: A nurse from the Psych ER called the Privacy Office letting the Privacy Officer (PO) know that an employee from Edible Arrangements called stating that they got medical information faxed to them on a Veteran that comes to the VA…

Outcome: Our doctor stated that he was told by a staff at outside facility to fax the paperwork to another number since the regular fax number was not working at the time. When doctor called back to the facility and attempted…