Veterans In Partnership (VISN 11)

Issue: Two documents were found by a VA employee outside an office on VA property. The documents contained a patient's name and partial SSN. The Privacy Officer (PO) investigated the incident and turned it over to Human Resources (HR) for disciplinary…

Outcome: Social worker received a reprimand for his failure to safeguard Veterans' documents.

Issue: Veteran A received Veteran B's medication in the mail along with his own. Veteran A returned Veteran B's medication to a VA Illiana Community Based Outpatient Clinic (CBOC). Update: 01/12/12:Veteran B will be sent a notification letter.…

Outcome: Pharmacy Supervisor has reminded staff of attention to detail and accuracy.

Issue: A VA Human Resource (HR) employee scanned Employee A's appraisal into employee B's eOPF file in error. The appraisal contained Employee B's full SSN and rating. Update: 01/09/12:Employee A will receive a letter offering credit protection services.…

Outcome: Credit monitoring letter has been sent to employee. HR has implemented a quality check in order to prevent a similar occurrence in the future.…

Issue: The Privacy Officer (PO) was notified 12-30-2011 that Veteran A received Veteran B's medication in the mail. Both were in the SARRTP program at the same time. Pharmacy holds the meds for the SARRTP patients. When the patients leave they…

Outcome: Pharmacy staff have been reeducated on the importance of double checking meds with mailers before sending to Veterans.

Issue: A VA employee sent an un-encrypted email message containing a screen shot of the full Social Security number and name of one of VA Providers to VetPro Help Desk e-mail group. The email group is outside of VA network. The…

Outcome: Per supervisor, employee re-trained on use of PKI when sending documents containing PII outside of the VA.

Issue: An employee at VA Illiana Health Care System reported that he suspected a co-worker had been accessing his medical record in CPRS without a need to know. Update: 12/20/11:There was verification from the supervisor that the co-worker accessed the Veteran…

Outcome: Disciplinary action taken against employee who accessed medical record without a need to know.

Issue: Veteran A received medication via UPS from the Peoria outpatient clinic which he thinks was the correct medication but the incorrect label. The label had Veteran B's name and medication information. Update: 12/14/11:Veteran B will be sent a notification letter.…

Outcome: Employees have been reminded of attention to detail accuracy.

Issue: VA Patient A sent a request to have certain documents copied from his medical record and sent to him and he received 36 pages of records belonging to VA Patient B with the same first and last name but a…

Outcome: The Release of Information (ROI) Supervisor re-educated the ROI Clerks and put additional quality checks in place.…

Issue: A nursing exit interview sheet for Patient A was given to Patient B in error. The sheet contained Veteran B's name, full SSN, diagnosis and medication information. Update: 12/13/11:Veteran A will be sent a letter offering credit protection services, as…

Outcome: Employees responsible have been educated to verify the Veteran prior to providing any information. All unit employees have been educated on the error and the issues with printing via the thin client and room "hopping".…

Issue: A Release Of Information release form was sent to Veteran A from North Central Consolodated Patient Account Center employees, the address in the computer was not accuratly updated by the Veteran, hence the letter and form were mistakenly opened by…

Outcome: Notification letter sent to the Veteran. Did not appear to be a VA employees error, Veteran did not change address in a timely fashion.…