VA Sunshine Healthcare Network (VISN 8)

Issue: A Release of Information clerk inappropriately disclosed records (full name, medical information and full SSN) on Veteran A to an a record retrieval company used by insurance carriers. The request was for another Veteran with the same name. Update: 08/26/11:The…

Outcome: The Veteran was mailed a credit protection letter. The Release of Information clerk who disclosed the records will receive disciplinary action and additional education/training.…

Issue: An outpatient pharmacy supervisor received a call from Veteran A stating that he received Veteran Bs medication at his address. The medication label contains: full name, medication prescribed, dosing directions, indication for use and provider's name. Veteran A stated the…

Outcome: Supervisor reviewed address entry process with employee involved. To help prevent future data entry errors the supervisor counseled employee on not running multiple applications of VistA at the same time. Employee involved retook Privacy and Information Security Awareness training. HIPAA…

Issue: A digital camera was left on a clerk's desk when a VHA employee came into office to clean. The camera was missing upon clerk's return to her desk Update: 08/25/11:The camera was used in the ENT clinic and had pictures…

Outcome: A&MMS modified policy to enhance accountability of all cameras/digital equipment issued.

Issue: A clerk in Release of Information at the Ft. Myers Outpatient Clinic mis-mailed Veteran A's labs and radiology reports to Veteran B. Update: 08/24/11:Duet to full SSN and medical information being disclosed, Veteran A will be sent a letter offering…

Outcome: This Veteran was mailed a credit protection letter. The Release of Information clerk will receive disciplinary action and additional education/training.…

Issue: A Veteran reported that his mother, whom is a VA employee, is looking at his VA medical record, and calling him about the information contained in his record. The Veteran reported this to the patient advocate at the Tampa VAMC…

Outcome: Service Chief working with Labor Relations on appropriate administrative actions. HIPAA notification letter mailed to affected Veteran.…

Issue: Veteran A called to report that he received the appointment list of Veteran B by mistake. The list included Veteran B's name, partial SSN and diagnosis and conditions. Update: 08/18/11:Veteran B will receive a letter of notification.…

Outcome: The Veteran has returned the list to the VA. Management and staff have been educated by the Privacy Officer regarding the importance of correct handling of Veteran notifications by mail. Notification letters were mailed 9/9/11.…

Issue: Veteran A called to report that he received a Compensation and Pension appointment notification letter intended for Veteran B. The letter contained Veteran B's name, address, home phone and protected health information (PHI). Update: 08/18/11:Veteran B will receive a letter…

Outcome: Management has been informed and education has been provided to appropriate staff regarding the importance of proper handling of patient information for mailing.

Issue: Veteran A alleges she received Veteran B's "authorization to report voucher for mileage allowance." The form contains Veteran B's full name, full SSN and address. Active investigation in progress. Update: 08/18/11:Veteran A is refusing to return the information of Veteran…

Outcome: Staff was re-educated.

Issue: Veteran A information was mail to the correct address but also included information for Veteran B. The letter's was stuff by the mail room automated machine. Update: 08/17/11:Veteran B will be sent a notification letter due to PHI being disclosed.…

Outcome: PO met with the mail room staff and discuss the problem with the Pitney Bowes machine in which sheets (letters) stick together during the process of inserting into the envelope. PO will contact to vendor for possible solution. Staff is…

Issue: A closed lid box marked "confidential" was reported missing from the locked medicine team room. It has been missing for approximately one week and included information on approximately 15 patients. Documents included H&Ps, EKGs, Team list, outside medical records. Update:…

Outcome: Policy reviewed on Shredder Bin program, contract reviewed, placement, appropriateness and number undergoing review. PO to be included in more clinical education venues.