VA Sunshine Healthcare Network (VISN 8)

Issue: A prosthetic employee found a VA Regional Office Claim Folder in a trash can on the basement near Prosthetic. Update: 04/26/11:Veteran A will be sent a letter offering credit protection services.…

Outcome: The C-file in question was located in a brown box with other empty boxes adjacent to it. The C-file was not visible due to the file being inside of the brown box. The corrective action in place is to monitor…

Issue: Veteran A received the medication reconciliation summary for Veteran B. Veteran A reported the violation to his Congressman who sent the matter to this facility. Patient Services reported the issue was closed with the Congressional Office. The Privacy Office (PO)…

Outcome: It was determined this was unintentional and the result of human error. The responsible physician was counseled and completed refresher VA Privacy and Security training. The Office has taken measures to ensure that this does not happen again.…

Issue: Veteran A was mailed Veteran B's Medical records, which included Veteran B's full SSN. Update: 04/04/11:Veteran B will be sent a letter offering credit protection services.…

Outcome: Supervisor notified and training provided. Credit Monitor letter mailed to Veteran.

Issue: Employee A inappropriately accessed Employee B's electronic medical record on several occasions. Update: 03/28/11:Employee B's name, SSN, and medical information was disclosed. Employee B will be offered credit protection services.…

Outcome: Further education provided to employee who inappropriately accessed record as well as supervisor involvement. Credit monitoring letter sent to Veteran/Employee whose information was inappropriately accessed.…

Issue: The Release of Information clerk mailed medical records on Veteran A to an insurance company. The insurance company requested records on Veteran B. Both Veterans had same last name. The Privacy Office will investigate. Update: 03/22/11:Veteran A will be sent…

Outcome: Employee involved re-education on ROI process and retook Privacy and Security training.

Issue: Veteran A received a UPS package with one prescription for her and one prescription for Veteran B. Privacy Office to investigate. The prescription had the name, medication and address of Veteran B. Update: 03/21/11:Veteran B will be sent a notification…

Outcome: Employee educated on preventing errors in the future and that this type of error has far more significant medical implications than an accidental PHI disclosure. Employee involved re-trained on Privacy and Security training. HIPAA notification letter mailed.…

Issue: A non Veteran called the Privacy Officer (PO) to inform her that a fax intended for a West Palm Beach (WPB) clinician was received at her personal residence. The fax was a four page pathology report for one of the…

Outcome: The woman is mailing the information to the PO for review. Letter offering credit monitoring has been sent to the Veteran. PO instructed the recipient to contact her with any future incidents. Sender has been contacted to inform them of…

Issue: Veteran A was handed Veteran B's appointment list by clinic clerk. Update: 03/16/11:Veteran B will receive a notification letter.…

Outcome: Document returned. Notification Letter mailed. Supervisor to counseled employee. Privacy Officer to schedule in-service for all section staff.…

Issue: Veteran A received a Medical Care Cost Recovery (MCCR) account activity statement and income verification statement in error, which was intended for Veteran B. Both Veterans have the same first and last names, but different SSN's and mailing addresses. Update:…

Outcome: MCCR Supervisor notified to confirm and correct addresses of both Veterans. Veteran A has returned the statement to VA Health Resource Center (HRC).PO confirmed that the supervisor has verified that the addresses are now correct for both Veterans. Notification letter…

Issue: Veteran A received Veteran B's appointment letter in the mail. The appointment letter was auto-stuffed in the envelope. The appointment letter contains the Veteran's full name, address, and appointment clinic, date, and time. Update: 03/11/11:Veteran B will receive a notification…

Outcome: Memo mailed to Veteran. Education provided to employee - clinic education planned.…