VA Southeast Network (VISN 7)

Issue: Employee requested assistance from HR to increase life insurance. A relatively new HR assistant had been assigned to his service. HR employee completed top portion of form for the employee but provided the name and fax number of the employee…

Outcome: Human Resource's employee counseled on proper completion of paperwork and to double check all data entry. It was a understandable mistake because the form asked for "email address and fax number" and employee thought it referred to employee requesting change.…

Issue: The Chief of Health Administration Service (HAS) contacted the Privacy Officer (PO) about Veteran A receiving Veteran B's (who is also an employee of this facility) medical information. Veteran A was sent to the Chief of HAS because Release of…

Outcome: Supervisor of Release of Information (ROI) instructed staff to check and double check information being mailed out. Employees have been instructed to check address on every piece of paper with the one showing on the envelope to be mailed.…

Issue: A Veteran employee made a written request to the Information Security Officer (ISO) for a report of co-workers who may have accessed his medical record without authorization. The Veteran employee made a further written request to further investigate several co-workers…

Outcome: Employees computer accounts were deactivated. HR Chief and Compliance Officer were notified of this incident.…

Issue: On 07/26/12, Veteran A visited the Dorn VA Medical Center Compensation and Pension (C&P) Clinic. Before leaving the C&P Clinic, he was directed to a photographer that took pictures to support his service connected disability. On the way back home…

Outcome: Staff has been re-educated on the need to safeguard patient information.

Issue: An address change was called in and the wrong Veteran's address was changed. Medications were ordered and sent out to the wrong address. The Veteran who requested a prescription called seeking delivery status of the medication and that is when…

Outcome: Manager of Centralized Scheduling Unit reviewed/discussed incident with staff members stressing the importance and significance of their actions. This unfortunate mistake could have resulted in serious injury (even death) if medication not prescribed was taken in error. On-going training is…

Issue: In a mailing of a letter from the Atlanta VAMC to a family member, the same envelope also contained two memo's with evaluation approval's for two other Atlanta VA Patients. PHI included full names and last four of the SSN's.…

Outcome: Staff involved were required to retake Privacy & HIPAA trng. Process was changed and SOP completed, all staff trained in new process.…

Issue: A former Veteran/employee complained that his supervisor inappropriately accessed his medical record in CPRS. The Privacy Officer (PO) is currently investigating the sensitive patient access report for the record being reviewed. Update: 07/29/12:The employee will receive a letter offering credit…

Outcome: Appropriate penalty or disciplinary action recommended in accordance with MCPM 00-13 Sanctions for Violations of Information Security and Privacy. Disciplinary action proposed (suspension or termination pending).

Issue: The Birmingham VA Medical Center (BVAMC) Privacy Officer (PO) was notified by an RN that he had faxed a document titled Medicine History and Physical (H&P Note) of the wrong patient to a vendor. The vendor contacted the RN to…

Outcome: Document was retrieved and education, training and awareness was given to the employee.

Issue: Veteran A received Veteran B's medical records in the mail. Veteran A contacted and delivered the medical records to Veteran B. Later, Veteran B contacted Veteran A to state that he/she had received Veteran A's records in the mail. Update:…

Outcome: Personnel counseled on importance of double-checking information prior to mailing it. In-service training has been scheduled for all ROI staff.…

Issue: Pharmacy Service staff reported that Veteran A contacted the Pharmacy Service staff on 07/18/12 and advised that he did not receive his medication. The medication was shipped by UPS on 07/11/12. The medication was last scanned into UPS on 07/12/12…

Outcome: The VA Police, and IG have been notified.