VA NY/NJ Veterans Healthcare Network (VISN 3)

Issue: A Nurse Manager reports that a binder containing Patient Care Plans is missing from the unit. The binder contained care plans on approximately 22 inpatients. The care plans contained the patients' current problems, short term goals approach, provider and nurse…

Outcome: A interdisciplinary team was convened to address how to handle the care plan binders and the electronic database, Accu Care. The team will continue to address how to update both the hardcopy and the electronic version of the care plan.…

Issue: Veteran A was given copies of his discharge instructions. Along with his copy, attached were copies of the discharge instructions for Veteran B. The discharge instructions for Veteran B contained his name and protected health information (PHI) including his diagnosis…

Outcome: Privacy Officer will provide additional face to face training to Nursing employees that fax sensitive personal information. Employees requested to review facility's current Privacy and FOIA policy. Encouraged employees to add fax number of the Dutchess County Department of Health…

Issue: The personally identifiable information (PII) of three patients consisting of physicians' pharmacy orders was discovered unattended on a countertop in the women's restroom. The orders included the patients' names, full SSNs and medication names. Update: 11/16/11:Three (3) patients will be…

Outcome: The documents were recovered and destroyed. Training and awareness activities regarding the safeguarding of sensitive patient information are ongoing with staff.…

Issue: An employee at the Veterans Center requested the Privacy Officer (PO) to run a report to see if anyone had accessed his medical records inappropriately. He identified three persons whom he stated had no need to know. Update: 12/01/11:One employee…

Outcome: Went over privacy regulations with employee who accessed medical record without a need to know and recommendation is for disciplinary action. No further action is required.

Issue: During a Peer Review Council Committee meeting two (2) cases were handed out to committee members, upon conclusion of the meeting the cases are to be returned to the chair, who then collects them and places them in the shredding…

Outcome: We have reminded the staff on the appropriate methods to use regarding the destruction of sensitive documents within the facility. We have put in place certain security measures (e.g. a shredding bin for sensitive information was place in the area)…

Issue: Magnetic resonance imaging (MRI) films were found on the elevator inside a cabinet by the Records Manager. Update: 11/01/11:The MRI films included lab result and name of one Veteran. The cabinet was found on the elevator when it opened. The…

Outcome: The department that was moving was reminded to check all drawers, cabinets, or other storage furniture to assure patient information is properly removed.

Issue: A Primary Investigator (PI) submitted a research protocol that was accepted by the Institutional Review Board (IRB). During a review it was discovered that the PI was using an offsite facility for biopsies and inaccurately reporting the location of the…

Outcome: PI's protocol is on hold until he receives the proper consents. He was also reminded that he must follow the policies and procedures that are in place to protect PHI.…

Issue: Clerical error resulted in Veteran A receiving Veteran B's Personally Identifiable Information (PII) in the mail and vice versa (Veteran B received Veteran A's PII). Information sent to Veterans A and B was the completed form 1010 EZ.. Veteran A…

Outcome: PO states we are conducting Privacy training sessions with the department from which the letters were sent. Veteran B mailed back Veterans A's form and it was received back to the facility on Tuesday 10/18/2011.…

Issue: A physician gave a routing sheeting to Veteran A which belonged to Veteran B. The nurse realized the mistake and contacted Veteran A at home and Veteran A told the nurse that he would shred the information in his personal…

Outcome: Provider was to make sure that he is given documents to the correct patient. Patient received credit monitoring.this was closed 10/28/11.…

Issue: A Hudson Valley employee inappropriately accessed a Veteran's medical chart numerous times throughout the year. This Veteran is possibly a family member of the employee. The Information Security Officer (ISO) is conducting a fact finding. Update: 08/29/11:The CPRS patient profile…

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.…