VA Sunshine Healthcare Network (VISN 8)

Issue: While performing Environment of Care (EOC) rounds in the Surgical ICU area, a member of the team found a box full with documents pertaining to Veterans and employees under a sink. The box was left open and unattended in a…

Outcome: Appropriate corrective actions should be given to Employee A for violations of VHA Privacy Policy CM No. 00-12-15 according to the Sanctions Clause V.A.5 (a,c&e).

Issue: A Clinic did an article for the Journal of Military Medicine and in one of the pictures 2 patients' names, DoB, and last 5 of the SSN can be seen clearly. The journal has already been mailed out and cannot…

Outcome: Service Chief reported a sit down meeting was held with the involved authors and a process review was conducted to identify how and why the error was made. As a result, our process for paper submission and our checklist will…

Issue: VA employee sat next to a person on a flight to Phoenix who was reviewing progress notes of a patient printed from CPRS. When asked, the person stated that he/she was a Miami VA Optometrist. The employee was able to…

Outcome: Notified service and provided further education regarding the proper safeguarding of PHI when transporting VA sensitive information.

Issue: A VA physician at NF/SG apparently entered into his spouse's medical record at the Pittsburgh Healthcare System. Update: 11/09/12:The investigation is ongoing.11/20/12:The employee indicated he entered the record by mistake and closed it as soon as he realized which patient…

Outcome: VA employee has been counseled and completed re-training on Privacy and HIPAA.

Issue: Veteran A's wife received a a denial letter of another Veteran B. Privacy will investigate. Update: 11/08/12:The spouse of Veteran A returned the top portion of a Fee denial letter intended for Veteran B to VA with a letter addressing…

Outcome: The Service resolved this issue back in May by no longer allowing volunteers to mail letters. VA staff is mailing Fee letters until they can obtain an automated letter folding system. HIPAA notification letter sent to the affected Veteran.…

Issue: The wife of a Veteran received payment from Accounts Receivable but the information on the document pertained to Veteran B - not related to wife. Update: 11/05/12:Veteran B will be sent a letter offering credit protection services due to full…

Outcome: Suprv of section is working with HR/LR for appropriate level of sanctions. Employee taking Privacy and HIPAA training. Review of process was completed.

Issue: Veteran A was handed the wrong appointment listing on 07/03/12 when he was scheduled for a four-month follow-on appointment. The error wasn't discovered until the Veteran arrived on 10/30/12 with the appointment list in hand for what he thought was…

Outcome: Employee has been counseled to exercise more caution when providing patients with their appointment listings and to verify all documents.

Issue: A Veteran brought in a letter addressed to him by the VA. Attached to the envelope on the upper right hand side was a yellow Post-It note with his full social security number and date of birth written on it.…

Outcome: VA employee involved completed re-training on Privacy and HIPAA. Credit monitoring letter sent to the affected Veteran.…

Issue: Compensation and Pension Physician took a VA Form 21-2507 in his pocket to the parking lot and returned to the office. There he noticed that the document was missing. He returned to the car but was unable to find it.…

Outcome: Sent letter to Veteran. Recommended sanction to employee as indicated in report.

Issue: Veteran A received Veteran B's EKG report at a pre-op clinic. Veteran A took the report to the Patient Advocate. The EKG report contained Veteran B's name, full SSN, date of birth and EKG results. Update: 10/26/12:Veteran B will receive…

Outcome: PO discussed situation w/HAS; Nursing; EKG; and Pre-Op staff on situation and need for awareness in document handling.