VA NY/NJ Veterans Healthcare Network (VISN 3)

Issue: A Release of Information clerk put another person's medical record in an envelope. The veteran returned the medical record to the medical center. The second Veteran is being contacted to see if he received this veteran's information. Update: 01/28/13:Veteran A…

Outcome: Supervisor of Release of Information Office went over policies and regulations again with employees. Disciplinary action is also being taken in this case.…

Issue: Three prescriptions for controlled substances for two Veterans were sent to the Castle Point campus via UPS. The package was signed for by a VA employee but the prescriptions were never sent to pharmacy. The prescriptions are now missing. The…

Outcome: Deliveries that do not belong to the Warehouse will not be accepted and/or signed for. Deliveries marked for the Pharmacy will not be accepted by the Warehouse staff. The tracking log currently in use, will be reviewed to implement a…

Issue: A Nurse Manager reports that a binder containing Patient Care Plans is missing from the unit. The binder contained care plans on approximately 24 inpatients. The care plans contained the patients' full name, diagnosis, nurse comments and discharge plans. Update:…

Outcome: Nursing Leadership discontinued use of the hardcopy version of the care plan binders on the medical unit. Nursing staff have been instructed to use the electronic version of the Accucare system. Nursing staff were issued read only access to Accucare…

Issue: A list containing patient full name, last four of social security number, Dx, HX, labs, Meds, and Ward was discovered in the cafeteria of the facility. The list is used by the Renal fellow who stated that she had it…

Outcome: The Resident was counseled regarding the seriousness of losing any document containing PHI. They must be aware of the document at all times and make sure it is secure. The service has decided to look at the information on the…

Issue: A list used by Residents containing a patient's full name, last four digits of the SSN, age, diagnosis, ward and room number was found by a shuttle stop that transport resident from our affiliate to the VA. The list was…

Outcome: The resident was counseled regarding the seriousness of losing any document containing PHI especially during transport throughout the facility. He was also reminded that protecting sensitive information is the responsibility of all employees.

Issue: A Release of Information Clerk included medical record documents belonging Veteran B in the envelope with Veteran A's medical processing. Update: 12/06/12:Veteran B will be seent a letter offering credit protection services due to full name and SSN being disclosed.…

Outcome: Employee was notified of the error in mailing and will receive counseling and has been advised to be careful and check thru all documents to ensure that the correctdocuments go to the correct Veteran.

Issue: Veteran A's wife reported that an envelope was received from centralized scheduling contained another Veteran B's appointment letter. Her concern is that perhaps her husband's information is in someone's possession. Update: 11/21/12:Veteran B will be sent a notification letter.…

Outcome: Privacy Officer spoke with staff and informed them of the potential risk involved when personally identifiable information is given to the wrong individual. They were asked toensure that they place the correct information in the correct envelope. The Supervisor of…

Issue: Veteran A inadvertently picked up Veteran B's routing slip. A nurse reported the incident and contacted the Veteran and asked for the routing slip to be returned. The slip contained veteran B's name, full SSN and date of birth. Update:…

Outcome: Staff was advised to ensure that the correct person is given the correct routing slip. Do not permit patients to pick up their own routing slip. Privacy concepts were reviewed.Staff indicated they would double check to ensure that each veteran…

Issue: Several VA employees accessed another employee's medical record Update: 06/12/13:The employee will be sent a HIPAA notification letter due to Protected Health Information (PHI) being accessed inappropriately.…

Outcome: Met with each employee along with their supervisor and it was identified that each employee inappropriately accessed the medical record of this employee.We discussed the need to know and it is inappropriate to access a medical record when the medical…

Issue: A Veteran initiated a complaint to the VA Police Service on 07/31/12. A Board of Investigation revealed that the alleged employee went into the Veteran's record without a need to know. Appropriate disciplinary action will be taken. Update: 09/20/12:Per the…

Outcome: A credit monitoring letter has been sent instructing Veteran to protect himself against identity theft. Disciplinary actions are pending.…