VA Southwest Health Care Network (VISN 18)

Issue: A Veteran (A) returned a box with a portion of another Veteran's (B) photocopied medical record information. The package was mailed via UPS from Medical Records Section per return address noted. The reporting Veteran's information was mixed in with another…

Outcome: Update 11/16/2012: Verification of fact-finding, remediation, and corrective action received from responsible Manager in Medical Records-Release of Information area noting that conducted fact finding on this case 11/13/2012 and found that the records were boxed wrong. During the last two…

Issue: A VA employee accessed the medical records of two other VA staff members. The employee did not have a business purpose for the access. Update: 10/16/12:Employee A and B, will be sent a letter offering credit protection services.…

Outcome: Fact finding has been completed. Employee has been disciplined.

Issue: At new employee orientation the wrong information was given to a VA employee. Information disclosed was full SSN, full name and DOB. The data is secured . It was reported by the employee who received the wrong information. Update: 10/15/12:Employee…

Outcome: Retrained staff and Service Line changed the way they process things.Credit Monitoring offered to employee.…

Issue: A former Employee's personnel folder was accessed by an unauthorized individual and left in an unprotected location for the weekend. It is unknown who saw the folder but one employee accessed it to obtain a telephone number to contact the…

Outcome: We have provided additional training to the employee so that additional problems do not occur in the future.

Issue: A staff member witnessed his co-worker accessing her ex-spouses CPRS record. This affects one veteran. Update: 10/02/12:The Veteran will be sent a HIPAA notification letter.…

Outcome: We have provided additional training to the employee so that additional problems do not occur in the future.

Issue: Yesterday late afternoon, 9/27/2012, Lab Manager reported that her employee found someone else's transcript in her eOPF record. This was initially reported to the Lab supervisor, and then subsequently to the PO and HR with the attachment. The exposed document…

Outcome: HR Chief and Supervisor provided education to HR staff for QM of HR files. Review of the 2 staff folders identified no further errors. The event occured more than 4 years ago. It could not be determined who made the…

Issue: Research coordinator reported that on 9/6, a veteran research subject (Veteran A) was accidentally given a CPRS patient inquiry printout for another veteran (Veteran B) with the same last name, which had apparently stuck to Veteran A's paperwork. Veteran B…

Outcome: Paperwork of Veteran B was recovered on 9/18/12. Staff were counseled by supervisor and Research PO on 9/18/12 not to print entire patient inquiry sheets to facilitate maintaining an Accounting of Disclosures, but to copy only the relevant information electronically…

Issue: An employee emailed patient information to the Union and the Union did not have the right to know. The information included name, partial SSN and diagnosis. Update: 08/04/12:The patient will receive a HIPAA letter of notification.01/08/13:An appeal was filed. The…

Outcome: This event was self reported by the nurse responsible. The mistake was realized and discussed with the Privacy Officer.

Issue: On 8/30/2012, the Pharmacy Supervisor reported to the Privacy Officer (PO) that Veteran B called the Pharmacy Helpline to report receipt of two medications for Veteran A, received by mail. Veteran A's medications were refilled and dispensed. The two medications…

Outcome: Although materials were not recoverable, agency received assurances that they had been disposed of securely by the time of the initial report. Medications were correctly refilled and dispensed. The root cause issue of failure to follow procedure in the Pharmacy,…

Issue: Employee alleges that supervisor was aware of a privacy incident and did not report it. Update: 11/20/12:Employee A looked at Emplyee B's CPRS record in appropriately. Employee B will be offered credit protection services.…

Outcome: Supervisor was given a proposed 14 day suspension as reported by Humasn Resources.