Veterans In Partnership (VISN 11)

Issue: Veteran A's lab results, as requested through the Release of Information (ROI) office, were inappropriately sent to Veteran B in error. Update: 04/29/13:Veteran A will be sent a letter offering credit protection services, as his lab results and full SSN…

Outcome: Education has been provided to the employee responsible. Credit Monitoring offer letter has been sent to the Veteran impacted by the error.…

Issue: An employee's day planner was stolen/taken on 04/23/13. It happened around 8:15 AMor so. The employee was leaving the Muncie Community Based Outpatient Clinic (CBOC) and getting the GSA vehicle filled up with his stuff. He placed his planner on…

Outcome: NA

Issue: Veteran A reported that a test kit he received on 01/30/13 had Veteran B's full name, full social security number and birth date on the plastic tube. The Veteran stated he threw the kit out into his garbage. Update: 04/15/13:Veteran…

Outcome: Contracted CBOC has re-educated all staff on the importance of double checking everything that is handed to a Veteran.

Issue: Veteran A was handed a test kit that had Veteran B's name, full social security number and birth date. He noticed this after he left the facility. Update: 04/15/13:Veteran B will be sent a letter offering credit protection services.…

Outcome: Contracted CBOC has re-educated staff on the importance of double checking anything handed to a Veteran.

Issue: A Fiscal clerk mis-faxed a credit card application which contained personally identifiable information (PII). The application has not been retrieved nor has it been returned from the location to which it was faxed in error. Update: 04/13/13:The Fiscal clerk located…

Outcome: Staff must verify fax numbers and recipient prior to sending faxes, make sure all faxes contain the appropriate verbiage which includes return instructions and contact telephone numbers. And eliminating their prior practice of not using a fax cover sheet as…

Issue: A Release of Information (ROI) clerk faxed a pathology report to a wrong number. The fax went to the home of a physician outside the VA. This physician had previously been a contracted employee. He knew to call and report…

Outcome: ROI clerk has been re-educated about faxing procedures.

Issue: A Fecal Occult Blood Test (FOBT) kit was handed to Veteran A at his appointment. He later noticed the kit had Veteran B's full name, full social security number and full birth date. Veteran A notified the VA hospital. The…

Outcome: The nurse has been re-educated on the importance of double checking the Veteran's name with anything handed to the Veteran.

Issue: Patient mailed specimen to us through USPS. When we received the package it had been damaged. The envelope was ripped, torn and re-taped closed by USPS. The content of the envelope contained a patient specimen vial including the patient's full…

Outcome: The laboratory staff were reminded to notify their supervisor immediately when they receive any packages that have been damaged or compromised during the mailing process. The Privacy Officer will discuss this issue with the file room supervisor.…

Issue: A recently terminated Community Living Center (CLC) Nursing Assistant inappropriately disclosed the name and diagnosis pertaining to one deceased Veteran and one current CLC resident. The inappropriate disclosure occurred via personal email accounts and on Facebook. Update: 03/29/13:Veteran A will…

Outcome: Notification letters have been sent, investigation turned over to VAPD for action.

Issue: A stack of documents was found which included a patient's full name, date of birth, full social security number, contact information, and very detailed information about the patient's medical and psychiatric care in numerous facilities including the JDD VAMC. These…

Outcome: The Supervisor is pursuing disciplinary action against the staff person responsible for this incident and will also have them re-take Privacy Awareness training.