VA Southeast Network (VISN 7)

Issue: Representative from a Congressional Office contacted the Privacy Officer to make her aware that they had received information from Veteran A that they were assisting. The facility mailed the requested documents and radiology CDs to Veteran A who in-turn took…

Outcome: Request corrected; information conveyed to Acting Public Affairs Officer for follow-up with Congressional Office. Incident referred to supervisor for appropriate disciplinary action in accordance with local medical center policy for privacy and information security violations. Audit of ROI request processed…

Issue: A VA employee found a copy of the Patient Census Report for an inpatient unit in the parking lot. The report contains the room/bed location, full name, and full SSN for 19 patients. Update: 09/23/11:The 19 patients will receive a…

Outcome: Nurse Manager unable to identify the employee who used the document; PO to provide privacy training for the unit staff.

Issue: Veteran A contacted the Patient Advocate to report that he had received another Veteran B's appointment letter in the mail. The letter contained Veteran B's Full name, last four (4), mailing address, and appointment date/time and location. Veteran A has…

Outcome: Document returned to the facility; Process for printing/mailing of appointment letters to be evaluated with the service line. Issue addressed with staff in order to increase awareness with handling the information. We are also evaluating the current process.…

Issue: Veteran A contacted the Outpatient Patient Pharmacy on 09/14/11 to advise that he had received medication instructions for Veteran B. Veteran A received instructions for Veteran B when he picked up his outpatient medications on 09/13/11. Veteran A received his…

Outcome: Employees are being re-educated on the need to safeguard patient information, and the importance of being vigilant when disbursing medication and instructions.

Issue: Veteran A presented to the Release of Information (ROI) office to report that he had received Veteran B's medical records in the mail. The documents were turned over to the Privacy Officer to investigate. Update: 09/09/11:Veteran B will receive a…

Outcome: ROI Supervisor notified of the event. The documents were returned and both requests were corrected. The employee was counseled and disciplinary action taken in accordance with the medical center's sanctions policy for privacy and information security violations.

Issue: On 08/17/11, the Privacy Officer (PO) received an envelope from an area Community Based Outpatient Clinic (CBOC) with a note from a clerk that indicated that Patient A received Veteran B's medical records when she received her own medical records.…

Outcome: The original documents were retrieved from the other patient and a copy has been placed in the administrative file.. The ROI clerk has retaken Privacy and Information Security training and provided documentation to the Privacy Officer and has been placed…

Issue: On 08/02/11, Veteran A and Veteran B arrived at the Columbia, SC VAMC Outpatient Pharmacy window and picked up medication refills. After Veteran A returned home, he reviewed the contents of the medication package and was surprised to see paperwork…

Outcome: The staff is being re-educated on the need to safeguard patient information.

Issue: Veteran A received 11 pages of medical records, which were intended for Veteran B. Both Veterans have the same first and last name. When Veteran A discovered the error, he presented the medical records to the VA County Service Officer…

Outcome: Staff is being re-educated on the need to safeguard patient information.

Issue: A patient called to state a Birmingham VA employee gave him the wrong fax number to the VA Regional Office. The number on the paper went to a elementary school in West Virginia. Per the patient, the area code given…

Outcome: Patient notified facility that an employee gave him the wrong fax number for Montgomery Veteran's Affairs Office. He used the number and his records went to a school in West Virginia. The Privacy Officer has requested the school return the…

Issue: A Veteran presented to an appointment and brought back six (6) bags of medication that he had received via USPS (United States Postal Service) belonging to other veterans. All six bags were batched incorrectly and mailed to the veteran on…

Outcome: HIPAA Notification Letters have been mailed on August 24, 2011. Re-education has been provided to staff by their supervisor pertaining to the handling and safeguarding of patients sensitive information.…