VA Southwest Health Care Network (VISN 18)

Issue: A VA employee accessed the records of a patient and an employee without a need to know and without authorization. The records include the name, address, date of birth, full SSN and protected health information . Update: 11/03/11:One (1) Patient…

Outcome: Service Chief issued Letter of Reprimand to employee.

Issue: An identification label from the 4A medical unit was found hanging on the Information Security Officer's (ISO) door. The information on label was a patient's first , last and middle name, full SSN, DOB and ward location. Update: 11/02/11:The Patient…

Outcome: It was undetermined where the label originated from. The label was hung on ISO wall outside his door. Training to staff on how to report a privacy violation and privacy violation guidance published in the facility newspaper. Offer Veteran credit…

Issue: Veteran A received an appointment letter which included his appointment information as well as the appointment information for Veteran B within the same envelope. The original appointment letters were provided to the facility Privacy Officer (PO) by Veteran A's wife.…

Outcome: 11/14/2011 Update and request for closure per uploaded, redacted letter of notification/offer of credit monitoirng. Corrective action documented per responsible supervisor as follows: Upon investigation responsible supervisor was able to track the incident and the person who caused the incident.…

Issue: Today, 10/24/11, at 4 PM, the Pharmacy supervisor reported to the Privacy Officer (PO) that Veteran A was discharged earlier today with 4 medications for Veteran B. Upon arriving home, Veteran A reported this to the Pharmacy by phone. He…

Outcome: Correct dispensing of RX education materials, verified with Pharmacy. Correct RX dispensing protocol was discussed by supervisor with LPN and RN. Both shifts were provided with education on medication reconciliation and also an additional protocol between shifts. Each employee was…

Issue: A Veteran initiated a privacy complaint in the Patient Advocate's office. He describes that his father received his laboratory results in the mail. After discussion with PO, he provided copies of his lab results and his father's medication consult which…

Outcome: Employee will be more diligent in checking Veteran identity issues for mail out. Unintentional error while covering another clinic in addition to her own. Offered supervisor additional PO education time with staff if needed.

Issue: An employee self-reported that one patient's medical information was accidently faxed to a wrong number. The information has not been returned. Update: 10/13/11:One patient will be sent a notification letter.…

Outcome: Education provided to employee and HIPAA Notification Ltr sent to Veteran.

Issue: An EKG label for one veteran was left on an EKG machine in a busy hallway on an inpatient ward. It is unknown how many people had access to this information. Update: 10/12/11:One Veteran will be sent a letter offering…

Outcome: We have provided staff with remedial training to ensure these kinds of incidents do not occur in the future.

Issue: An EKG label for one veteran was left unattended on an EKG machine. The machine was located in a busy hallway on an inpatient ward. Update: 10/12/11:One Veteran will be sent a letter offering credit protection services due to full…

Outcome: We have provided staff with remedial training to ensure these kinds of incidents do not occur in the future.

Issue: The Pharmacy Supervisor reported on 10/11/11 that medications for Veteran A were dispensed to Veteran B on 10/07/11. Veteran B did not take any of the medications provided to him and returned medications and education materials to the pharmacy today.…

Outcome: The supervisor met with employee again to review procedures for dispensing medications at the window, i.e., requesting ID card and last 4 of SSN. The supervisor reinforced privacy concepts tied to safety of dispensing medications.…

Issue: The Release of Information Clerk processed a request for a copy of Veteran A's medical information and mailed it in a sealed envelope. USPS returned a portion of the mailing envelope with a form stating empty wrapper was found separated…

Outcome: Staff are now mailing larger documents in boxes instead of envelopes.