VA Sunshine Healthcare Network (VISN 8)

Issue: A fee basis referral letter with the name and address of Veteran A was mailed to several veterans. In the past, the process used a window envelope and the address showed through. However, on this set of letters they wrote…

Outcome: All 72 patients were called and asked to either return the letter or ensure that it is destroyed. Patients that could not be contacted after two phone calls have been sent a letter outlining the same instructions. Both employees involved…

Issue: Two separate mis-mailings of prescription medications were reported by a Veteran. The information involved was a patients name, prescription number, medication name, dosing directions, indication for use and providers name. The medications involved have been either returned to VA or…

Outcome: Veteran's address corrected to prevent future mis-mailing. Employee involved completed re-training on Privacy and Information Security Awareness. The MAS Service Chief working with Labor Relations on formal disciplinary action. Pharmacy Service will remove computer keyboard shortcut to prevent future mis-mailing…

Issue: A Quality Management Specialist discovered a sheet of paper with three patients names, last four digits of the SSNs, and test results from anticoagulation clinic. The sheet was laying face-up on a projector cart in a conference room and was…

Outcome: Employee was verbally counseled regarding necessity to properly safeguard patient data and reminded to cross-check room before leaving.

Issue: Veteran A received a copy of a consult request for Veteran B. The consult request was mis-mailed by a clerk in Geriatric Services. Veteran A and Veteran B have the same first and llast name and same last four of…

Outcome: The affected Veteran was mailed credit monitoring letter. Since we were unable to determine the specific employee responsible for the event all those responsible for mailing out this type of information was provided additional training by privacy office and supervisor.…

Issue: A paper copy of a Consultation Report intended for Hematology/Oncology Service was inadvertently mailed to another veteran. Veteran A received Veteran B's full SSN, full name, DOB, and medical information. Update: 02/10/12:Veteran B will be sent a letter offering credit…

Outcome: Information has been returned to the Privacy Officer. CBOC Manager has been informed of the incident and a determination of human error has been concluded. Appropriate CBOC staff have been reminded of the importance of accurate mailing procedures to safeguard…

Issue: Veteran A received a copy of Veteran B's lab results. The lab results were mis-mailed by a clerk in Release of Information. Update: 02/09/12:Veteran B will be sent a letter offering credit protection services.…

Outcome: Veteran B was mailed a credit protection/monitoring letter. The employee responsible for the incident has been asked to retake the Privacy & HIPAA training. Their supervisor will be following up with human resources for any disciplinary action. Veteran A returned…

Issue: A VA Patient who is also an employee complains that several co-workers have been accessing his health record in CPRS. Update: 03/01/12:The Patient/Employee will be sent a letter offering credit protection services due to full name and full SSN being…

Outcome: Education to all section employees and sanctions provided to employees involved.

Issue: A VA Imaging Service CT Technologist faxed several Radiology CT Scan Orders to a local middle school by mistake. The mis-faxed orders included sensitive information pertaining to four Veterans, including name, full SSN, date of birth and protected health information…

Outcome: Four Veterans were sent credit protection letters. The employee responsible for the incident has re-taken the Privacy & HIPAA training and their supervisor will be following up with HR for any disciplinary action. All employees in this area have been…

Issue: Veteran A called reporting that an appointment letter belonging to Veteran B was mailed to him in error. The appointment letter contains the full name, address, last four of SSN, and medical appointment information for Veteran B. The Privacy Office…

Outcome: Employees involved have been retrained on Privacy and Information Security. Steps have been taken to ensure that it does not happen again. Employees involved have given assurances that they understand the rules regarding patient privacy and the importance of following…

Issue: A Pharmacy technician gave the prescription bag for Patient B to Patient A. Patient A discovered the error after arriving home. Patient A did not open the bag, but observed the back page of the prescription label, which identified the…

Outcome: Employee was administered a verbal counseling and given a copy of the pharmacy services policy to review.