Veterans In Partnership (VISN 11)

Issue: Patient A received Patient B's medication in the mail. The information that was disclosed included patient B's name, address, diagnosis, and medication. A VA employee was dispatched to retrieve medication. Update: 04/20/11:Patient B will receive a letter of notification.…

Outcome: Staff were educated on following correct procedures for changing a address.

Issue: FOBT (fecal occult blood test) cards with a Veteran's full name and full social security number were sent to another Veteran. Update: 04/12/11:The Veteran will be sent an offer for credit protection services.…

Outcome: Credit monitoring letter sent to Veteran. Educating staff who send FOBT cards to Veterans.…

Issue: A VA Police Officer found a patient list in Surgical waiting room. The list contained an unknown number of patients' name, full SSN, and protected health information (PHI). Update: 04/06/11:Twelve (12) Veterans will be sent letters offering credit protection services.…

Outcome: Clinical staff has been reminded to keep all notes secure or shred them after use.

Issue: A completed VA Form 10-10 (Application for Health Benefits) was mailed to Veteran A, included in the envelope was a letter for Veteran B. The letter contained Veteran B's first name, DOB, and full SSN. Update: 04/05/11:Veteran B will be…

Outcome: Information was returned and staff was reeducated on proper handling of confidential information

Issue: Veteran A received a copy of her lab test results in November, 2010. She just took them out of the envelope and realized they were Veteran B's. The information disclosed included Veteran B's name, SSN, and lab results. Update: 04/01/11:Veteran…

Outcome: Staff were educated on the proper handling of confidential information. Information was retrieved.…

Issue: VA Neurosurgery Contract staff transmitted/stored VA patient personally identifiable information (PII) and protected health information (PHI) including name, last four digits of the SSN and diagnosis, to a non-VA website found at http://www.editgrid.com. The site is an on-line spreadsheet where…

Outcome: The Contractor has submitted an Action Plan and they are working with OI&T to find a solution that complies VA security policies, while at the same time, accomplishing the necessary goal of providing continuity of care for VA patients.

Issue: Medication for Veteran A was given in error to Veteran B. Information disclosed included Veteran A's full name and medication type. Veteran A was given Veteran B's medication, Veteran A immediately noticed the error and informed the Pharmacist. Veteran B…

Outcome: All Pharmacy employees were counseled as to the proper process of verifying prescriptions (emptying bins one at time) in order to prevent a similar occurrence in the future. Notification letters sent to impacted individuals (2).…

Issue: A family member of a VA employee reports finding progress notes in a box while unpacking the box. The progress notes and hand-written notes are presumed to be made by the VA staff member. Update: 03/21/11:The nineteen (19) Veterans affected…

Outcome: This information was being used by the employee for documentation for her yearly reviews. An in-service will be conducted at the May Supervisory Academy to inform all that patient information may not be used for this purpose. Disciplinary action is…

Issue: On 02/03/11, the Eligibility Coordinator entered a backlog of approximately 2000 patients into the Enrollment Applications System (EAS), which is a national electronic VistA file that dates back to 2002. Some patients have made address corrections since the original application…

Outcome: Eligibility/Enrollment staff have been retrained to follow the following sequence of events for data entry of each individual eligibility application (link to patient file, print online application, verify signature, file application) in order to prevent a back log of records…

Issue: Release of Information Staff mailed medical records to the wrong patient. Update: 03/04/11:Due to only last 4 of SSN and no date of birth being exposed, Veteran A will receive a notification letter.…

Outcome: The staff member responsible for this error has been notified and appropriately counseled. All HIM staff members that provide release of patient information services have been reminded to verify all documents before placing in mail envelopes.…