VA Southwest Health Care Network (VISN 18)

Issue: An end of shift report with 18 Veterans' name and full SSNs was found on an EKG machine in a hallway. It was printed out on 04/05/11 and not found until 04/08/11. Update: 04/11/11: the 18 Veterans will receive a…

Outcome: Sent letters to all veterans whose information was disclosed. Providing free credit report monitoring for all veterans involved. Provided staff in this section with addition training on how to maintain and secure patient information.…

Issue: Medical information was mis-faxed. It should have been faxed to University Medical Center and was faxed to University of Arizona campus. The receiver immediately took it to the University's Privacy Officer who contacted me. She secured the information. The information…

Outcome: Staff was given additional training for faxing information in a more secure manner.

Issue: Veteran A alleges that an employee is disclosing his information to Veteran B. Update: 05/05/11:Veteran B will be sent a letter offering credit protection services.…

Outcome: Supervisor will work with Human Resources to apply appropriate sanctions to employee.

Issue: Veteran A has filed a complaint with facility Director's office regarding a Prosthetics letter he received with Veteran B's information. His complaint noted that he had received an additional sheet of paper with Veteran B's full name, full address and…

Outcome: Chief for area reviewed safeguards for mail-out, re-trained staff, and put in place double check mechanism prior to any mail out of Prosthetics information. Employee counseled regarding mail-out of confidential data and double checking. Submitted: JWinstead, Privacy officer EPVAHCS…

Issue: Employee A a requested Sensitive Patient Access Report after she was told by a VISN employee, Employee B that Employee As medical conditions were the subject of a lunch conversation. Employee A was not present at the lunch attended by…

Outcome: Discussions with supervisors about planned disciplinary actions. Disciplinary actions in review and pending, per HR confirmation.

Issue: A VA employee scanned a document to create a PDF file on VA equipment. It created a PDF using the online feature of Acrobat.com because the equipment was configured incorrectly. The patient's full SSN and lab results were uploaded to…

Outcome: The configuration of the scanner was improper. This has been corrected. The user was educated to always confirm that the file is not saved accidentally off the VA network.

Issue: An email notification came from the Office of the Inspector General (OIG) that Veteran A turned in information he received on Veteran B via mail. The documentation was recovered. Update: 03/14/11:The information included Veteran B's medical information and his full…

Outcome: On the spot education/training provided to ROI relief employee.

Issue: Wife of a Veteran A filed privacy complaint as she had received copy of Explanation of Benefits form which included one other Veteran's (Veteran B) full last name, initial of first name, and full social security number as related to…

Outcome: Supervisor for Finance area conducted fact-finding and mitigation/corrective action after determination that clerical error was sent to Austin for processing of claim with EOB printed out as filed by the clerk at our facility. This was a data entry error;…

Issue: An employee reported that she believes her personal medical electronic records were accessed without permission or a need to know by several employees and she is requesting a full investigation of the access logs from 02/15/11until 03/02/11. Update: 03/07/11: The…

Outcome: 04/04/2011: Update to ticket - Per fact finding, determined that access was unauthorized and received notice per NSOC-SPE of need for letter of notification/credit monitoring. Letter drafted and then signed per facility Director with note that appropriate action taken to…

Issue: PO was notified that medications and education sheets were intended for one Veteran and received by another by mail. On February 18, 2011, Veteran A returned medication and education sheets meant for Veteran B to CBOC Pharmacy. No medications had…

Outcome: ROC written by employee involved in providing medication to another Veteran in error. Re-education by Pharmacy Ass't Chief and performance improvement review of medication dispensing in this CBOC.