VA NY/NJ Veterans Healthcare Network (VISN 3)

Issue: Employee A accessed Employee B's medical record without authorization. Employee A informed Employee B of a medical diagnosis listed in Employee B's medical record. Employee A is not treating Employee B and is not part of the treatment team. Update:…

Outcome: Both employees were educated on the Release of Information process. Employees were provided Privacy factsheet Volume09, No.3 which provides guidance on the use and/or access of protected health and individually identifiable information by VHA employees. Employees required to review local…

Issue: An employee assigned to a Root Cause Analysis team left a cover sheet with personally identifiable information (PII)and blank documents in ladies' bathroom. Update: 08/16/12:Individual A will be sent a letter offering credit protection services.…

Outcome: Reviewed privacy policy and training material with staff.

Issue: The following information of 5 patients participating in a research protocol was sent to the SPRINT Central Database at Wake Forest University. Name, age, ethnicity and blood pressure were entered in the database without the patient signing an informed consent…

Outcome: Training was given to the research coordinators stressing the importance of getting patients to sign all forms before any interventions or interactions can occur with the participant.

Issue: Patient A came in to see his physician and in the process was given a copy of his lab results. When he got home and looked at them, Patient B's information was included also. His daughter called and was upset…

Outcome: Staff was reminded not to allow patients to remove any documents from their desk. All documents are to be double check before giving it to any patient for accuracy.…

Issue: An amendment request document is missing within the service. The provider said he provided it to his secretaries, but they do not have the documents. The documents contained the patient's name, address, date of birth, full SSN and protected health…

Outcome: Staff was interviewed and reminded how to safeguard VA sensitive information so this does not happen again.

Issue: An employee inappropriately accessed a Veterans medical record. The Information Security Officer (ISO) will complete a fact finding on the employee. Update: 07/19/12:A nurse was looking at the record of a Veteran who was previously in a relationship with her…

Outcome: Service Care Line will take appropriate disciplinary action. Employee will take recommended training. Rule of Behavior will be completed and signed. A credit monitoring letter was sent to the Veteran.…

Issue: Patient A requested a copy of his EMG report. The Release of Information (ROI) clerk printed out the report from the electronic medical record and mailed it to the patient on July 10, 2012. The ROI supervisor received a call…

Outcome: The PO educated the employee on how to check documents for accuracy before sending them to the requester. The employee was reminded of the process that was put in place to prevent this type of incident from happening. Disciplinary actions…

Issue: A research study staff member forgot to have 10 subjects sign consent forms and HIPAA authorizations while recruiting new subjects. Demographics and blood pressure were entered into the sponsors database. Update: 07/09/12:The 10 subjects will be sent a notification letter.…

Outcome: Notification letters have gone out and redacted copy of the letter has been uploaded. The Primary Investigator and the research staff member were retrained and are in the process of obtaining the consents.…

Issue: An employee needed to disclose information pertaining to a state law under a standing request. In addition the employee needed to disclose 7332 information so the employee had the Veteran sign an authorization (10-5345). In the information to be disclosed…

Outcome: The privacy officer met with the employee who reported event. Employee is well aware of the error made and will not make the mistake again.…

Issue: Veteran A received copies of Veteran B's medical records. Veteran A requested copies of medical records and received his own medical records and (8) pages of Veteran B's lab results and other medical records. Update: 07/19/12:Veteran B will be sent…

Outcome: This incident will be used to initiate a Preventive Ethics issue cycle. The Preventive Ethics team will review the current process to determine which areas in ROI need improvement.…