VA Southeast Network (VISN 7)

Issue: Medical reports belonging to Veteran A was inappropriately released to Veteran B. The documents were received in the mail from Veteran B today with a note that reports were sent to her in error. Veteran A's documents were included in…

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

Issue: A VA LPN found a patient's medication reconciliation sheet in the parking lot when she was leaving the clinic to go home. The sheet was locked away before the employee went home. There were no recent face to face visits…

Outcome: Document was retrieved by staff and back in VA control. Staff were reminded of privacy safeguard procedures, to check their pockets, not to remove PHI/PII from work areas.…

Issue: Veteran A left a voice mail with the Release of Information Clerk that she received copies of her records but they contained about 40 pages of information (full SSN and medical information) that belonged to Veteran B. Update: 07/11/12:Veteran B…

Outcome: Personnel were counseled on importance on double-checking information before mailing it. An in-service training date for all ROI staff is scheduled.…

Issue: Veteran reported to his provider that he received lab results for 3 other patients in the mail along with his information. The lab reports contain the Veterans names, mailing address, and biopsy results. The Veteran has returned the information to…

Outcome: Documents returned to the medical center. Incident addressed by supervisor during staff meeting.

Issue: A Release of Information Office (ROI) employee received a request for records from USAA Life Insurance Company. According to the ROI employee, the correspondence listed the Veteran As name, with no social security number. The employee searched CPRS, and located…

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

Issue: During the transfer of a Veteran, a clerk released the wrong discharge summary to an affiliate state war Veterans nursing home. The Health Information Management (HIM) Director received the information and immediately contacted the VA and had the documents returned.…

Outcome: Document returned. Corrective action recommended in accordance with medical center policy for violations of information security and privacy.

Issue: A Compensation and Pension (C&P) doctor had files with PII & PHI on 3 Veterans on her desk. Another Veteran and his wife came in for an appointment. They placed numerous documents on the doctor's desk. When they gathered their…

Outcome: Employee reminded of importance of safe-guarding and safe-handling of veteran's records and best practice is not to have other records on desk when patient is in the office; put them in desk drawer. Veterans notified of incident on July 9,…

Issue: Veteran A contacted the Pharmacy Service staff on 06/19/12 regarding not receiving his medication (Oxycodone). The Pharmacy Service staff member contacted the UPS representative who advised that the Pharmacy label was mislabeled. The medication was delivered to Veteran B. The…

Outcome: The VA Police Chief has been notified for further investigation.

Issue: On 6/23/2012, Veteran A received an appointment letter reminding him of an upcoming appointment. The Veteran was surprised to see a second appointment letter, which was intended for another Veteran. Veteran A contacted the Privacy Officer by phone to report…

Outcome: STAFF HAS BEEN RE-EDUCATED ON THE NEED TO SAFEGUARD PATIENT INFORMATION.

Issue: A Patient Advocated reported to the Privacy Officer that he received a telephone message from Patient A stating when he was at the Birmingham VA Medical Center for an appointment, he was given an appointment schedule for a follow-up appointment.…

Outcome: Education/training will be provided to PCS staff on the viewing documents prior to providing to patient. PCS management will conduct this training and report to PO when completed.