VA Sunshine Healthcare Network (VISN 8)

Issue: A VA Employee mismailed financial and medical information of Veterans A-D (four Veterans total) to Veteran E along with Veteran E's claim/benefit application. Update: 06/13/11:Veterans A, B, C, and D will be sent letters offering credit protection services.…

Outcome: Credit monitor letters were mailed to four Veterans whose information was involved. The Employee responsible for this incident was educated and asked to retake the VHA Privacy Policy Training in TMS. The employees supervisor was also involved for any further…

Issue: A Bay Pines VA employee faxed medical records to the wrong fax number. They were faxed to an investment company that called and forwarded the information back to the Bay Pines VA. The information disclosed included the Veteran's name, address,…

Outcome: Employees supervisor notified and education for faxing records has been provide to the employee.

Issue: A Financial Management System (FMS) employee found 14 labels containing patients' full name, full SSN, date of birth and ward location on the floor hallway entering the ward. Update: 06/08/11:Fourteen (14) Patients will be sent letters offering credit protection services.…

Outcome: Spoke with charge nurse and Unit Nurse Manager and recommended that an alternate method be used to transport labels with patients to appts., such as a pocket, envelope in the medical record.Attached email with request for closure, closing ticket.

Issue: Veteran A received a medication list that belonged to Veteran B. Veteran A has returned the list to the VA. Update: 06/07/11:Veteran B will be sent a notification letter.…

Outcome: Education has been provided to the appropriate staff by the Privacy Officer. This was an oversight on the part of the provider; there was no malicious intent, but genuine concern for the patient.

Issue: A nurse manager discovered a document sent through g-mail between medical residents. The e-mail contained seven (7) Veterans information, partial SSN, last name, and medical information. Update: 06/03/11:Seven (7) Veterans will be sent a notification letter.…

Outcome: Supervisor and PO counseled individual clinicians. Chief of Staff took actions with clinician program oversight leadership to enhance and elevate penalties for future violations.

Issue: Lab specimens were disposed of because the sample was exposed for too long. Update: 05/31/11:The patient will be sent a letter offering credit protection services, due to full name and full SSN being exposed.…

Outcome: The Acting Chief of the Laboratory Service has reeducated the all staff members on the closing procedures for the Laboratory Service. In addition, during the monthly staff meetings, the acting chief will be going over the closing procedures to ensure…

Issue: Folders containing outpatient mental health clinic appointment lists were placed in an unsecured drawer over the weekend. Upon arrival to duty this morning, the Medical Administrative clerk found the labels were removed from the folders and the lists were out…

Outcome: The total number of patients to receive letters offering credit protection is 96 due to duplicate patients on the lists having multiple clinic appointments for that same day. Providers in the clinic have been educated to use the VIEW option…

Issue: Colonoscopy preparation instructions were mailed to the wrong patient. The instructions contained the Veteran's last name, first initial and last 4 digits of the SSN. No other identifiers were in the instruction sheet, nor was any date specified for the…

Outcome: Nurse Manager developed an action plan to reinforce to nursing staff at next staff meeting the importance of protecting PHI, being more diligent and careful with documents, and proofreading before mailing out any documents to ensure the right correspondence is…

Issue: A Release of Information clerk mailed Veteran A's Audiology report to Veteran B. Update: 05/12/11:Veteran A will receive a letter offering credit protection services.…

Outcome: Training was conducted with the staff member and education given on the importance of checking all mail outs before sending. Supervisor was involved and submission to HR has been taken for disciplinary action.

Issue: A private company received a fax of a Veteran's clinic schedule. The fax was shredded and the facility notified. Update: 05/09/11:The elements that were reported were the name and SSN. The faxed sheet, which was shredded, looked like a clinic…

Outcome: Supervisory chain of command notified of incident. Direct supervisor reviewed situation with clinic staff and reviewed correct procedures for faxing of PHI and III to off site locations. PO will conduct follow up training at CBOC site with all admin…