VA Sunshine Healthcare Network (VISN 8)

Issue: Veteran A received a copy of Veteran B's appointment reminder letter along with his own. The letter contains Veteran B's full name, mailing address, last four digits of the SSN and information related to his appointment (clinic location, date and…

Outcome: The information was returned to the Privacy Officer. The employees who are responsible for mailing out these type of letters have been asked to apply additional safeguards when mailing out Veteran's personal information. The supervisors were instructed to discuss this…

Issue: A VA employee handed a Benefit Travel Worksheet to Veteran A that contained the full SSN of Veteran B. Update: 04/30/12:Veteran B will be sent a letter offering credit protection services.NOTE: There were a total of 168 Mis-Handling incidents this…

Outcome: A copy of the worksheet was provided to the Privacy Officer (PO). It was determined that this was a result of human error. Veteran A verified with the Medical Administration Service (MAS) Supervisor that all of the other information on…

Issue: Veteran A received Veteran B's Fee Services denial letter. Veteran A mailed the letter to Veteran B who reported this mis-mailing. The denial letter contains the full name and address of Veteran B. Privacy Office will further investigate. Update: 04/27/12:Veteran…

Outcome: Re-design/engineer the process to eliminate the possibility of mix ups in envelope stuffing. The employees involved retook Privacy and Information Security Awareness training. HIPAA Notification letter mailed to affected Veteran.…

Issue: A Veteran received an appointment list with 3 other Veteran's full names, full social security number and clinic names along with his appointment letter. The Veteran returned the list to the VA. Update: 04/24/12:Three Veterans will be sent a letter…

Outcome: The employee and volunteer were given more training on the handling of mail and the importance of checking the information being put it into the envelope. The Supervisor was notified and advised the employee to review all letters before giving…

Issue: A VA RN accessed her spouse's medical records using CPRS 40 times over the last 11 months. Update: 04/24/12:One Veteran will be sent a letter of notification.…

Outcome: PO spoke with the Veteran and explained he needs to call his clinic or clinic scheduling for his appointment information and his spouse must use ROI (VA Form 10-5345) that is signed by him with specific medical information, dates, and…

Issue: VA Employee/Veteran A has contacted the Privacy Officer (PO) to report that his VBA Comp & Pension documentation was received by Veteran B in error. The documentation contained Veteran A's name, address, full SSN and diagnosis. Update: 04/20/12:Veteran A will…

Outcome: The Veteran has returned the mailing to the employee, stating that he did not 'look at anything'. Letter offering credit monitoring has been mailed to the Veteran on 4/30/12. Please consider this incident resolved and proceed to close the ticket.

Issue: Veteran A was inadvertently handed Veteran B's appointmernt list during a routine visit. Veteran A returned the appointment list two days later to the Community Based Outpatient Clinic (CBOC) from where he originally received it. The list contained Veteran B's…

Outcome: Clerk has been verbally counseled on importance of patient safety and security. Supervisor has also examined the process he uses to verify patient identity.…

Issue: Patient A received Patient B's medications in the mail. Update: 04/19/12:Veteran B will be sent a notification letter.…

Outcome: Education provided to employees. Management review of processes and procedures, and implementation of systems redesign for reduction in error.…

Issue: A VA employee found a folder in the VA coffee shop and it had 26 prosthetic consultation documents with Veterans' full names, full SSNs, addresses and phone numbers. The consultations were left by a another VA employee. All the documents…

Outcome: The employee was provided extra training for safeguard of all documents with PHI and PII. The supervisor was notified and the consults will be transported in a locked bag from now on until the consults can be automated and printed…

Issue: Veteran A received Veteran B's test results along with his own. Veteran A returned the lab results to his Primary Care Team, who in turn notified the team leader who subsequently contacted the Privacy Officer (PO). Subsequent examination of the…

Outcome: The contractor advised Mailroom staff to fan/flip paper stack prior to inserting into sorting machine. This will discharge any static buildup in the paper. Humidity tolerances within mailroom noted to be within limits.…