VA Sunshine Healthcare Network (VISN 8)

Issue: Facility Privacy Office received a report that one of our outpatients who had a GI procedure received another patient's report. Service to obtain report from Veteran A and contact Veteran B to determine if he received Veteran A's report. Update:…

Outcome: Process changed in handling the discharge information. Staff involved completed privacy re-training.Complainant letter mailed. HIPAA notification letter mailed to affected patient.…

Issue: Veteran presented to an outpatient clinic appointment and returned paperwork for two other veterans that he received in the mail in error. Update: 02/09/11:Veteran B and C will receive a notification letter.…

Outcome: Supervisor was notified. Education was provided to the appropriate staff to prevent reoccurring.Notification letters mailed to two veterans 3/1/2011. IRCT notified, so that ticket may be closed.…

Issue: A Release of Information clerk mismailed Veteran A's medical records to Veteran B's attorney. Update: NA…

Outcome: The records have been retrieved. The clerk involved has been further educated by the Privacy Office and supervisor. Credit monitoring letter has been mailed.…

Issue: Patient B's appointment letter was put into the same envelope as Patient A's Appt letter. Patient A called telephone triage and they advised its return. Patient A mailed the appointment letter on 1 Feb and it was received today, 7…

Outcome: HAS clerks and volunteers cautioned to exercise more diligence when stuffing envelopes. This incident was briefed at HAS weekly meeting and is being emphasized to others.…

Issue: Veteran A received Veteran B's prescriptions in the mail. Veteran A and Veteran B have the same name. Veteran A did not realize the medication were not for him, until Veteran B called Veteran A at his home telephone number…

Outcome: Provided notification to Veteran. Staff educated on the importance of verifying accuracy of information.…

Issue: US Postal Service delivered a prescription refill to the wrong address. The individual who received the package opened it and discovered it wasn't addressed to him. He in turn hand-delivered it our Pharmacy for safekeeping. The package was correctly addressed.…

Outcome: Redacted letter sent.

Issue: Veteran/patient picked up (or was given) a printed appointment letter and medical record progress note containing PHI for another veteran/patient after discharge from a surgical procedure at this facility. This Privacy Office will further investigate and confirm if another veteran/patient…

Outcome: Employees involved completed re-training on VHA Privacy Policy Web and VA General Privacy and Information Security Awareness and Rules of Behavior.Service modified the processing of patient discharges to avoid recurrence.Credit monitoring letter mailed. Complainant letter mailed.

Issue: Medical information (one veteran) was inappropriately faxed to a non-medical office. Update: 01/31/11:Veteran will receive a letter offering credit protection services since his full SSN and DOB were exposed.…

Outcome: Letter mailed to veteran 2/24/2011. IRCT notified so that ticket may be closed.

Issue: A VA employee found patient information from the Pyxis medication dispensing machine on the floor within the facility. Update: 02/01/11:This involved one patient, and included his social security number and date of birth. It was generated and evidently misplaced by…

Outcome: The Anesthesiology Service was contacted to review policies and procedures with Service staff. Education will be provided to the Service by the Privacy Officer regarding the safe handling/disposal of information containing personally identifiable information (PII) & protected health information (PHI).…

Issue: Veteran A received Veteran Bs CD labeled with full name, full SSN and X-ray images. Veteran A returned CD to Privacy Office at this facility. Privacy Office will further investigate and confirm if Veteran B received Veteran As CD. Update:…

Outcome: Radiology file room staff retook privacy training.Established a new policy for retrieving a CD from the file room window. Radiology staff and the patient will verify that the information on the CD is correct and that they are receiving the…