VA Southwest Health Care Network (VISN 18)

Issue: Patient X-Ray was left in employee meeting room. Update: 02/17/11:Veteran A will receive a letter offering credit protection services.…

Outcome: Clinic staff members reminded of the importance of proper handling of sensitive patient information during staff meeting.

Issue: Full Social Security number on document mailed to Veteran A was showing through envelope window. Document mailed to Veteran A's home address via US Postal Service. Veteran A brought envelope and enclosed document to a Supervisor at the VA due…

Outcome: 02/28/2011 Update: letter of credit monitoirng notification provided to Veteran. Note that corrective action/mitigation taken by responsible supervisor to address inappropriate mailing with actions to include: review of all processes leading to the incorrect mailing, stopped this type of mailing…

Issue: Nurse was on speaker phone with a Veteran discussing his medical condition and test results. This was overheard by at least one employee and other employees were in exam rooms nearby with other patients. It is possible others overheard this…

Outcome: Proper procedures reviewed with staff member.

Issue: Show Low CBOC notified the Privacy Officer of an apparent Privacy breach. United States Postal Service (USPS) delivered a large manila envelope late yesterday, 2-2-2011. Inside the envelope was VA inter-office envelope containing 12 Release of Authorization forms (VA form…

Outcome: Retrieval of documents. Staff education provided by Supervisor regarding Privacy elements of secure internal mailing for all staff - staff meeting. Credit monitoring letters sent to 12 Veterans. Authorization forms sent to ROI to log disclosures. Ticket closure requested.

Issue: While seeing patients in clinic on 1/20/11, a patient told pharmacist that stapled to the back of his medication reconciliation handout was a letter to a different patient regarding an upcoming appointment. The patient received the handout upon checking in…

Outcome: Since this type of error has occurred multiple times, the facility director has informed the supervisory staff and the Human Resources staff that each offense will result in an automatic reprimand. A letter to all employees was sent to inform…

Issue: A veteran called to say that he received the medical record of another veteran instead of receiving his own information. Update: 01/19/11:Veteran will receive a letter offering credit protection services since his full SSN and DOB was exposed.…

Outcome: Supervisor has counseled employee.

Issue: An employee walking by a blue shred bin noticed that papers were sticking out and accessible to the public. Update: 01/11/11:PO states thirty - four (34) names was on the list. Unknown how long it was like that. It was…

Outcome: Unalbe to determine the responsible person in this case. Credit monitoring letters have been sent 1/13/11.

Issue: Employee A was witness to and reports that employee B improperly disclosed sensitive health information to another employee about a family member of employee A. Employee B was unaware that the patient being referred to was related to Employee A.…

Outcome: Supervisor counseled employee responsible for event.

Issue: Two letters were mailed to the wrong veterans; the letters contained sensitive information. Update: 01/05/11:Veterans A and B will receive a letter offering credit protection services.…

Outcome: Supervisor has re-inforced the importance of care when dealing with patient information.