VA Sunshine Healthcare Network (VISN 8)

Issue: A VA Clinic Nurse mailed Veteran A the written prescriptions belonging to Veteran B. The prescriptions contained Veteran B's name and medication names. Update: 09/10/12:Veteran B will be sent a notification letter.NOTE: There were a total of 20 Mis-Mailed incidents…

Outcome: The employee was counseled by the supervisor and training was provided.

Issue: Veteran A received Veteran B Travel Voucher denial letter containing Veteran B's full name and SSN. Veteran A is n the process of returning the voucher to this Privacy Office. Update: 09/10/12:Veteran B will be sent a letter offering credit…

Outcome: Unable to determine what staff member mailed document, therefore supervisor provided education to all section staff.

Issue: Employee A brought 2 print jobs (job was printed twice) that was found on a printer (SURG6) In reviewing the print job, there are a total of 9 patients information listed, to include PHI. The email was printed from a…

Outcome: VA has taken specific administrative steps to ensure that this does not happen again and reminded staff of the importance of safeguarding PII and PHI.

Issue: On August 29, 2012 Veteran A was discharged from surgery and a nurse gave him the next three appointments of Veteran B. Veteran returned the appointment lists today. Update: 09/10/12:Veteran B will be sent a notification letter.…

Outcome: a. Appropriate corrective actions should be given to employee for violations of VHA Privacy Policy CM No. 00-12-15 according to the Sanctions Clause 5.0.b. Since it has become a frequent violation the discharge of Veterans, a specific training should be…

Issue: A provider disclosed results of a "positive-for-alcohol" urinalysis report to the patient's supervisor. The patient was getting routine medical care from the provider. Both patient and supervisor are VA employees. The patient is a Work-Study student. The provider incorrectly believed…

Outcome: Reaffirmed with Provider that HIPAA Privacy Rule applies to VA employees--no exceptions. Same for supervisor.

Issue: Employee complained that co-workers were inappropriately accessing his medical records using CPRS. Update: 12/26/12:One employee will be sent a letter of notification.…

Outcome: Sanctions were recommended against one employee for inappropriately accessing the other employee's patient record. Employee was reprimanded 12/17/12.

Issue: Veteran A received Veteran B's "Request for Outpatient Services" form (VA 10-7079) in the mail. The envelope had Veteran A's address, but Veteran B's name as the addressee. Veteran A returned the envelope and a cover letter to the nearest…

Outcome: The FEE clerk has been advised to exercise more caution when addressing these envelopes, since he was already corresponding with both Veterans and that leads to errors.

Issue: Veteran patient was discharged after an outpatient surgery and provided a packet with post operative instructions. After a few weeks, the Veteran was going to dispose of the information when he realized that at the end of his packet was…

Outcome: Education provided to nursing staff of the recovery area. Awareness about printed documents and picking up information from printer in a timely matter was discussed.…

Issue: Veteran A received his appointment letter and a copy of Veteran B's appointment letter in the same envelope. Veteran A notified Telecare who directed him to mail the letter to the Privacy officer, which he did. Veteran B's letter contained…

Outcome: At the next team meeting this incident will be discuss and all members cautioned to crosscheck appointment letters before mailing, since this was a hand-stuffed envelope.…

Issue: Veteran A received his fee letter and a fee letter for Veteran B. The letter contained the full name and last four numbers of the social security number for Veteran B. The Privacy Office will further investigate. Update: 08/17/12:The letter…

Outcome: Employee involved will no longer mail letters but will call Veterans. Employee involved re-took Privacy and Information Security training. HIPAA Notification Letter mailed to affected Veteran.…