VA New England Healthcare System (VISN 1)

Issue: The charge nurse came to notify the Nurse Manager that a Veteran approached her and handed her a packet of papers. The Veteran stated "someone left these in the table". They were an assembly of medication due lists for Oct…

Outcome: Employee educated and possible disiplanary actions being taken as this is in adddition to other non privacy employee issues.

Issue: Veteran A had an appointment yesterday and upon checking out was handed paperwork. When Veteran A arrived home he looked at the paperwork and realized there were documents for Veteran B and Veteran C in the package. Veteran A returned…

Outcome: The Privacy Officer (PO), along with Service Manager, could not identify the responsible employee. It was reported that the Veteran who received the paperwork may have picked it up off of a desk since the Veteran was walking into a…

Issue: A Veteran recieved a progress note for another Veteran in the mail. The Veteran sent the infomation to the Facility Director. Update: 10/24/12:Due to full SSN and medical information being exposed, Veteran B will be sent a letter offering credit…

Outcome: MSAs were educated on the error and the process has changed to give staff a second review prior to sealing the envelopes. This will aid in cutting down mis mailings.

Issue: Veteran A reported to the patient advocate that a provider had Veteran B's information on paper in plain sight for him to view. Veteran A reported the full name and full SSN of Veteran B to the patient advocate. Update:…

Outcome: Employee to secure patient information in folder during appointments. PO sent email (and discussed in person) to provider that patient information must be locked up when not in use and if she steps out of her office.…

Issue: A Veteran complained that his wife dropped off his application. Per the Veteran, it was handed to Eligibility or the Information Desk. Staff were queried and it was unable to be determined that the information was given to the VA.…

Outcome: Staff will continue to look for the information but based on the information provided by the V( who got the information from his wife) we are unable to determine that the document was delivered to the VA. After further follow…

Issue: Veteran A, who is also a reporter for a local newspaper, recieved an envelope addressed to him that had Veteran B's appointment information. Update: 10/15/12:Veteran B will be sent a HIPAA notification letter.10/29/12:The letter meant for Veteran A was mismailed…

Outcome: The mis-mailed letter came from the Mental Health clinic. It appears that a clinic employee accidentally put the wrong letter into the wrong envelope. The employees supervisor was notified about this incident and the employee was given additional guidance about…

Issue: Veteran A received a prescription for Veteran B. The report states that the medication was handed out at the pharmacy window. Update: 10/15/12:Veteran B will be sent a HIPAA notification letter.NOTE: There were a total of 149 Mis-Handling incidents this…

Outcome: Employee was educated on the importance of double checking scripts and Patient IDs prior to releasing meds.

Issue: Employee A telephoned PO to report that employee B's information was placed in employee A's e-OPC account. PO investigating. Will contact HR to remove information and confirm that employee A's information is in the correct e-OPF. Update: 10/17/12:Employee B will…

Outcome: Responsible employee was visited by the Facility ISO and their scanning process was reviewed. PO counseled the responsible employee along with requiring re-completion of VA Privacy and Information Security and National ROB training. Notification letter w/credit monitoring mailed to compromised…

Issue: Veteran A received information on Veteran B in the mail from the Release of Information (ROI) Department. Veteran A returned the information to the Community Based Outpatient Clinic (CBOC), so that it could be returned to the correct Veteran. The…

Outcome: The Supervisor addressed this with the employee. He was re-educated on the importance of protecting patient information and making sure to double check envelopes before mailing.…

Issue: Patient A was handed a CD in an envelope that had his name on it. When he got home, he discovered that the actual CD has Patient B's name on it. Patient A did not view the CD. There is…

Outcome: Referred to supervisor who will put processes in place to prevent it from happening in the future.