VA Southwest Health Care Network (VISN 18)

Issue: PO from another VA reports that Contracting employee received medical records in an inner office envelope from our facility. This was directed to her department and delivered by facility mail staff. There were 11 pages of 1 medical record which…

Outcome: The Mailroom was notified to monitor anything unusual in this regard. The mailroom was NOT a contributing party. They do a fine job of continuous checks and returns of improper mail. At both facilities, the mailroom operated appropriately. It's a…

Issue: A label containing one Veteran's full name, full SSN, and DOB was found on an EKG machine on an inpatient ward. Update: 09/27/11:The Veteran will receive a letter offering credit protection services.…

Outcome: PO have provided addtional training for all staff members.

Issue: A label containing one Veteran's full name, full SSN, and DOB was found on an EKG machine on an inpatient ward. Update: 09/27/11:The Veteran will receive a letter offering credit protection services.…

Outcome: PO have provided addtional training for all staff members.

Issue: A Veteran reported receiving mis-faxed documents at his personal fax number in past several weeks from VA with information regarding patients' names and information for authorizations for care, information referring patients for medical care in community. Was upset at VA…

Outcome: 11/30/2011 Letter of notification with offer of credit monitoirng drafted and forwarded to Director for signature. Additionally, Action Plan developed per recommendation of Privacy Officer and at request of Director to address other identified issues and assure resolution (need for…

Issue: A package containing hand-written prescriptions for sixteen (16) patients was sent from the main facility to one of the Community Based Outpatient Clinics (CBOC). FedEx has lost the package and after tracking, it is deemed lost. Each prescription contained: the…

Outcome: The contractor completed its internal tracking process and could not locate the package. PO have re-educated staff on what to do in these situations and are also working the contractor to improve customer service.

Issue: A package containing hand-written prescriptions for seven (7) patients was sent from the main facility to one of the Community Based Outpatient Clinics (CBOC). FedEx has lost the package and after tracking, it is deemed lost. Each prescription contained: the…

Outcome: The contractor completed its internal tracking process and could not locate the package. We have re-educated staff on what to do in these situations and are also working the contractor to improve customer service.…

Issue: Employee A mailed lab results to the wrong address, which contained Veteran full SSN and medical information. Update: 09/12/11:Veteran B will be sent a letter offering credit protection services.…

Outcome: Supervisor contacted to provide education to employee about checking documents to send out and to record disclosures of PHI. Confirmation of education pending. Supervisor has counseled employee regarding event and double checking of envelope mailings of medical records. He also…

Issue: Veteran A received Veteran B's appointment list instead of their own. The appointment list included Veteran B's name, last four digits of the SSN and diagnosis. Update: 09/06/11:Veteran B will receive a letter of notification.…

Outcome: Probable source department has fully investigated matter and were unable to determine the source of the breach. Supervisors have counseled front line staff regarding policies and procedures when dealing with privacy issues and will continue to do so.…

Issue: Veteran/employee complaint is an individual accessed his record without authorization. Update: 10/03/11:Veteran Employee A will receive a letter offering credit protection services.…

Outcome: VA employee access found to be inappropriate on the follow dates in December 12/03/2010, 12/09/2010, 12/16/2010. The access was in CPRS which contained SPHI. Sanctions were suggested and to re- train the employee.

Issue: Veteran A was being in seen in dental was supposed to be scheduled for labs. The clinic staff inadvertently made an appointment Veteran B with the same last 4. They then gave Veteran A the appointment reminder with Veteran B's…

Outcome: We notified the Veteran and provided additional training to the staff member involved.