VA Sunshine Healthcare Network (VISN 8)

Issue: Veteran A received paperwork relating to one prescription (no drug) in his package that belonged to Veteran B. The paperwork contained the full name, address, prescription number, doctor's name, drug name, and drug information for Veteran B. The Privacy Officer…

Outcome: Safeguards in place require all paperwork to be verified in two places: filling and checking. Double check verification will be reinforced with entire staff and with outpatient pharmacists during staff meetings. Employees involved counseled and re-took Privacy and Information Security…

Issue: The Medical Support Assistant (MSA) from 4J Ward gave a discharge summary pertaining to Veteran A to the son of Veteran B. The son did not noticed it until visiting the Outpatient Pharmacy office and being given other medicine that…

Outcome: Appropriate corrective actions should be given to the employee for violations of VHA Privacy Policy CM No. 00-12-15 according to the Sanctions Clause 5.0

Issue: The Facility Management Support (FMS) Automated Data Processing Application Coordinator (ADPAC) reported finding three appointment lists of Veterans (5 Veterans total) in a printer. Update: 08/16/12:Five (5) Veterans will be sent a notification letter due to Protected Health Information being…

Outcome: Re address issue presented to CIO on July 15, 2010 to restrict printers only to specific areas according to the users workplaces. This would reduce the risks of Veterans privacy violations and would promote better practices at handling Veterans personal…

Issue: Veteran A reported to Primary Care that he received a copy of his diagnostic follow up letter along with letters belonging to two other Veterans. The letters contained the full name, full SSN, DOB, home address and medical condition of…

Outcome: Employees responsible for handling the Veterans' individually identifiable information have been provided training and awareness by the Privacy Office and supervisors were included. Employees will implement additional safeguards while handling this information. Credit Monitoring letters were mailed to the two…

Issue: Veteran A also received Veteran B's lab results in the same envelope as his own. Veteran A mailed the lab results to Veteran B, who subsequently notified telephone triage. The lab results contained Veteran B's full name, address, and CT…

Outcome: Mailroom clerks have been asked to "fan" stacks of test results before placing them in the hopper for automatic mail out, which consists of machine folding and stuffing each letter into an envelope.

Issue: Veteran A was handed a screen-shot of Veteran B's appointment information when he presented at the main clinic. Both Veterans have the same last four digits of the SSN. Veteran A didn't discover the error until after arriving home, whereupon…

Outcome: HAS clerk cautioned to be more careful when preparing this type of information for patients, especially when preparing envelopes.

Issue: During a TJC Tracer round, two quality management employees found documents pertaining 85 Veterans lying in the 6K Nurse Station Printer. The 6K ward was vacated since 01/20/12, but two doctors had access to an office nearby. The 6J ward…

Outcome: PO states it was impossible to identify the employee who left the documents unattended. However, privacy awareness training was given to all employees by supervisor.…

Issue: The family members of inpatient Veteran A reported that food for Veteran B's liquid food was delivered to their family members room. The food label listed Veteran B's full name, last 4 and type of liquid diet, room number and…

Outcome: PO unable to substantiate staff error, however Nurse Manager provided awareness training to unit staff.

Issue: Veteran A was having a procedure done at an outpatient clinic when a VA employee invited their child into exam room as a procedure was taking place. The child who is not affiliated with clinic was exposed to the physical…

Outcome: This privacy incident was communicated with the employee's supervisor. Staff was reminded that employees must use and/or share information only as permissible within the scope of those duties. Information about our Veterans should not be shared with non-VA employees or…

Issue: A Veteran alleges someone changed his address in the system to an unknown address and the Veteran is concerned that correspondence and supplies meant for him (prosthetic and medications) may have gone to the incorrect address. Update: 08/06/12:It was confirmed…

Outcome: Notification Memo mailed. Supervisor notified of incident. Staff error resulted in the address change. Svc Chief and Supervisor advised to at a minimum have employee re-take mandatory privacy training and to contact Labor Relations for appropriate disciplinary actions.…