VA Southwest Health Care Network (VISN 18)

Issue: An electrocardiogram (EKG) printout was found still connected to an open EKG machine in a busy hallway on an inpatient ward. This affected one (1) patient. Update: 08/29/11:The document was left unattended for over 30 minutes and contained the patient's…

Outcome: The patient was notified and the Privacy Officer provided staff with additional training to ensure that this type of incident does not occur again.

Issue: A label used for Electrocardiograms (EKG) was left on an EKG machine in a busy hallway in an inpatient ward. This was for one (1) patient. Update: 08/29/11:The patient will be offered credit protection services, since his full SSN was…

Outcome: We notified the Veteran and provided staff additional training to ensure these types of incidents do not occur again.

Issue: A Veteran employee is questioning why another VA employee accessed his medical records through CPRS on the following four dates: 07/10/11, 06/27/11, 07/03/10, 06/13/09. Update: 09/06/11:The employee did not have a need to know and should not have been accessing…

Outcome: All four accesses were found to be inappropriate. The Service Line Manager and Human Resources were notified and the Privacy Officer suggested sanctions.

Issue: Veteran A received an appointment reminder with Veteran B's reminder in the same envelope. The wrong reminder will be returned to the Privacy Officer (PO) today. The letter contained Veteran B's full SSN and medical information. Update: 08/19/11:Veteran B will…

Outcome: Staff completed its internal tracking process and could not locate the package. The PO has re-educated staff on the need to ensure that the appointment reminders go to the correct Veteran and are also working to improve customer service.…

Issue: A copy of Veteran A's medical record was returned to the facility by Veteran B. The medical record information in packet consisted of a copy of the medical record with full patient name, full SSN, encounter information, laboratory, pharmacy, and…

Outcome: 09/28/2011: Note that original packet of information which had been incorrectly labeled and received by incorrect Veteran was returned in total by the Veteran who had received the incorrect package - to originating Section - Medical Records/Release of Information staff.…

Issue: VA Employee/Veteran complaint is that supervisor demanded the VA Employee/Veteran's Medical file. The VA Employee Veteran handed it over in fear of losing his job. The medical records were then disclosed to a Human Resource Officer without the Veteran/employees consent.…

Outcome: Veteran/employee medical records along with 7332 information were disclosed in January of 2010 without a written release from the Veteran/employee. Based on th P.O. inquiry this constitutes a breach. The inquiry was full of inconsistencies. Suggestion was to conduct an…

Issue: A VA Occupational Health employee sent her own employee health information via inter-office mail to another VA employee and the document is now missing. The information contained her name, partial SSN and personal medical information. Update: 08/17/11:Due to health information…

Outcome: The employee who sent the document was retrained on how to mail interoffice documents properly. The employee whose information is missing was advised on risk management options while the search for document was occurring. This included reporting to their bank,…

Issue: Veteran A was given Veteran B's appointment follow-up sheet at checkout from the clinic. Veteran A is mailing the list back to the facility. The appointment follow-up sheet contained Veteran B's name, address, full SSN, date of birth and diagnosis…

Outcome: Letter was sent to Veteran and staff was given additional training to ensure this type of incident does not occur again.

Issue: A label was found on an EKG machine on an inpatient ward. It was there for approximately 15 days before it was brought to the PO. Update: 08/09/11:The patient, whose full name, full SSN and date of birth were on…

Outcome: Letter was sent to Veteran and staff was given additional training to ensure this type of incident does not occur again.

Issue: An EKG printout was found on an EKG machine on an inpatient ward. These machines are left in the hallway where anyone can see the information. Update: 08/09/11:The patient whose full name, full SSN, full date of birth and PHI…

Outcome: Letter was sent to Veteran and staff was given additional training to ensure this type of incident does not occur again.