VA Southeast Network (VISN 7)

Issue: On December 15, 2010, Ms. As personal confidential medical records were forwarded to the Central Alabama Veterans Health Care System (CAVHCS) Human Resources (HR) Department in Tuskegee, without her consent, and used as evidence to support and justify a Request…

Outcome: Interim PO recommeded to Acting Associate Director that an Administrative Board of Investigations is convened, as the Interim Privacy Officer has no prior privacy background, privacy training, or experience conducting investigations. AIB could conduct a thorough investigation and report findings…

Issue: Veteran A reported that he received Veteran B's appointment reminder letter in the mail. The letter contained Veteran B's name, address, appointment date/time, and provider name. Update: 07/29/11:Veteran B will be sent a notification letter.…

Outcome: Letter returned to the Privacy Officer. PO and ISO reviewing current process for printing and mailing of appointment reminder letters.

Issue: Following an Emergency Room (ER) visit on 05/13/11, Veteran A presented to the Release of Information (ROI) Department and requested copies of her ER visit. After reviewing the medical records, she was surprised to see that Veteran Bs personal health…

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

Issue: On 7/25/2011, the Dorn VA Medical Center File Room Supervisor received a FedEx box which contained forty-three Home Health Medical Records dating from 1993 to 2005. The Job Corps purchased a file cabinet during a VA excess property sale. A…

Outcome: Logistics is currently checking all equipment to ensure medical files have been removed before the equipment is transferred/disposed. The medical facility will continue to reinforce the importance of safeguarding patient information, by communicating and educating all staff who comes in…

Issue: A bag of medications for Veteran A was placed in the bag of Veteran B. Veteran B who received the medications of Veteran A took the medications to the Pharmacist at his Community Based Outpatient Clinic. The pharmacist stated the…

Outcome: Per supervisor, employee was counseled to make sure medications are properly packed and labeled. This incident will be discussed at Pharmacy staff meetings as education regarding privacy issues and the ramifications that can result. Employees are to be aware and…

Issue: On 7/20/11, Veteran A arrived at the Dorn VA Outpatient Pharmacy window and presented three handwritten prescriptions. The Pharmacy Technician was surprised when she realized that the prescriptions were written for three different individuals and by two different providers. The…

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

Issue: Veteran A, who was discharged from inpatient care on 07/20/11, called to report that she had received Veteran B's MD Discharge Instructions from her Nurse at the time of discharge. The documents contain Veteran B's full name, full SSN, diagnosis,…

Outcome: Patients contacted; Medical center management notified; process for receipt of documentation at the time of discharge reviewed with the Nurse Manager along with the process for processing the documentation post-discharge. Employee counseled per medical center policy for sanctions for privacy…

Issue: Patient A received a copy of pharmacy discharge instructions for Patient B. Both patients were discharged the same day and same unit. Patient A contacted the privacy officer and faxed the information. Update: 07/14/11:Patient B will receive a letter of…

Outcome: Patient A, who received the wrong information, did return the original documents to the Privacy Officer. Patient B, whose information was given to the wrong patient, has been sent a notification letter. Training was provided by service and processes are…

Issue: On 06/27/11, Veteran A received an envelope by mail from the Dorn VA Medical Center. The Veterans wife opened the envelope. In the envelope was a new VA ID Card, with a picture another person, not Veteran A. The Veterans…

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

Issue: While on Environment of Care (EOC) rounds the Information Security Officer (ISO) discovered paper in a trash can that listed full name, SSN, and medications for 14 patients. Update: 07/07/11:The paper was found in a day room where patients watch…

Outcome: All the paper was shredded. The supervisor of that ward provided training to all personnel on disposal of PII. The Privacy Officer has prepare credit monitoring letters which will be mailed after the Director signs. PII print capability has been…