Veterans In Partnership (VISN 11)

Issue: Clerk mailed a letter to Patient A, that contained xray results to Patient B Update: 02/28/12:Patient B will be sent a notification letter due to PHI being disclosed.…

Outcome: Staff were re-educated on the importance of utilizing the double check system for all mail outs. Notification letter sent and scanned, attached.…

Issue: An Authorization for AIS Access form was sent to a network printer in the Logistics office. It contained an employee's first and last name and her full social security number. Update: 02/28/12:The employee will be sent a letter offering credit…

Outcome: There is no way to figure out who sent the AIS form to the specific printer. OI&T has enabled auditing on the specific printer in case it would occur again. We will then be able to tell who sent the…

Issue: Veteran A was handed Veteran B's progress note by a VA employee. Update: 02/29/12:Veteran B will be sent a letter offering credit protection services.…

Outcome: Staff were educated on the importance of verifying correct patient prior to handing hard copy records to patients. Credit Monitoring letter sent and a redacted copy scanned and uploaded.…

Issue: Patient A received Patient B's list of medications in error. The list also contained Patient B's name and partial SSN. Update: 02/28/12:Patient B will be sent a letter of notification.…

Outcome: Supervisor has discussed need to double check Vista and CPAS informaton before handing out or mailing anything to the patients.

Issue: A Human Resource (HR) Specialist sent a With out Compensation (WOC) data sheet to prospective WOC employees that contained information on another WOC student. Information at risk full SSN, full name, DOB, home address, and phone. Update: 02/15/12:The WOC will…

Outcome: Human Resources employees responsible for this process have been made aware of the error. They have also been advised to create a "read only" blank document to be used to send to prospective WOC appointees, in order to prevent a…

Issue: A compensation and pension appointment letter was sent in error to another Veteran (two letters in one envelope). Information disclosed was Veteran B's full name, address and partial SSN. Update: 02/15/12:Veteran B will be sent a notification letter.…

Outcome: C&P staff have been educated on the error and how to properly separate individual letters, in an attempt to increase awareness and prevent a similar occurrence in the future. Notification letter has been sent to the Veteran affected by this…

Issue: An appointment letter was mailed to Veteran A with another envelope was attached to it. It appears the envelope was not sealed properly. No specific information is known at this time. The Privacy Officer (PO) is trying to reach the…

Outcome: The supervisor found this incident was due to operator error. He is in the process of writing a SOP and a training document on how to use the equipment properly. Each employee will be trained on the processes. A double…

Issue: Veteran A was mistakenly given Veteran B's Medication list which included Veteran B's Full name and SSN. Update: 02/07/12:Veteran B will be sent a letter offering credit protection services.…

Outcome: Staff involved in the incident have been re-educated.

Issue: Test results were mailed to a Veteran. The Veteran received the test results on both 01/31/12 and a duplicate set on 02/01/12. Neither envelope was sealed. The information at risk includes the Veteran's name, address and lab results. Update: 02/01/12:Veteran…

Outcome: The supervisor found this incident was due to operator error. He is in the process of writing an SOP and a training document on how to use the equipment properly. Each employee will be trained on the processes. A double…

Issue: Two paper charts for new admissions to Ward 14-2 came up missing. The two Veterans were admitted on 01/20/12. The unit clerk states that the charts were made up the same day as admission, however, when he went to file…

Outcome: Although the breach could not be confirmed, credit monitoring offer codes have been provided for two Veterans. Employees have been educated on properly safeguarding sensitive information.…