VA Sunshine Healthcare Network (VISN 8)

Issue: A VHA clinician sent an unencrypted email with VA protected health information (PHI) in the form of photographs and radiology images to her private email accounts and accessed and stored those images on her personal equipment. The email also included…

Outcome: Administrative action is ongoing as the event involved conflict of interest, privacy and HIPAA, failure to follow policy, misuse of resources, and gratuities. Director is working with VISN, General Counsel, and HR on extent of administrative action and final resolution.…

Issue: A Human Resource (HR) Specialist mis-mailed another employee's retirement papers to the wrong employee (also stated for retirement). The recipient (a VA doctor) returned the errant paperwork to the HR Specialist, who in turn mailed it to the correct employee.…

Outcome: The employee was verbally counseled and all HR staff reminded to exercise greater vigilance when preparing packages for mail out. Added emphasis placed upon cross-checking contents with address name.…

Issue: A Home Based Primary Care provider left a medical progress note for Veteran A that belonged to Veteran B during a home visit. The progress note contained Veteran Bs protected health information (PHI). The progress note belonging to Veteran B…

Outcome: Employee who incurred this mistake has retaken Privacy and Information Security training. Also, other staff will be forewarned of the potential for such accidental mishandlings of protected patient information that is printed to a multi-use printer. Credit monitoring letter mailed…

Issue: Veteran alleges that his provider discussed his medical condition with his employer when the employer called the provider about the doctor's note she had written excusing the veteran from work. Update: 01/31/12: The Provider acknowledged she discussed two facts of…

Outcome: Provider was counseled regarding limited disclosure of information.

Issue: A clerk in release of information mismailed Veteran A's lab results to Veteran B. Veteran B returned the documents to the release of information department. Update: 12/22/11:Veteran A will be sent a letter offering credit protection services due to full…

Outcome: The affected Veteran was mailed a credit protection letter. The employee who was responsible for the mis-mailing of the patient's medical records was further educated and trained in Privacy & HIPAA awareness. Their supervisor will be following up with any…

Issue: Veteran A received the discharge instructions for Veteran B while checking out of a clinic after his procedure. A VA employee handed Veteran A six pages of which one page belonged to Veteran B. The paperwork contained Veteran B's name,…

Outcome: Incident reported to Nurse Manager for staff awareness.

Issue: A social worker left a completed VA Advanced Directive next to the Veteran A's bedside while sleeping. Veteran A shared a room with another Veteran. The Advanced Directive had patient's full name and full social security number. Veteran A reported…

Outcome: This event was self-reported by the Veteran. We have mailed him a credit protection letter. The social worker who was responsible for the mishandling of this information was educated by Privacy Office and asked to retake the Privacy & HIPAA…

Issue: A list of appointments intended for Patient A was provided to Patient B. Both patients had the same last name and an appointment in the same clinic. The appointment listing contained Patient A's name, last four digits of the SSN,…

Outcome: Awareness education provided to those involved and notification sent to the Veteran.

Issue: Veteran A presented to the Patient Advocate's Office with diagnostic test results and a notification letter received in the mail, which contained medication information and a list of upcoming appointments of Veteran B. Update: 12/14/11:Veteran B will be sent a…

Outcome: Notification letter mailed to the Veteran on 12/21/11. Education was provided to the staff regarding the appropriate handling and mailing of patient information.…

Issue: VA Employee reported to the ISO that an i-STAT, which is a handheld blood analyzer, was reported missing from the Lab. Update: 12/07/11:Nine (9) Veterans will be sent letters offering credit protection services due to full SSN being accessible on…

Outcome: The Lab Service Chief got technical assistance from the i-STAT representative and has validated that there are nine (9) full SSNs displayed in this instrument, dating from 7/21 - 7/29/11. The Service Chief has worked with the representative to set…