Veterans In Partnership (VISN 11)

Issue: Patient A and Patient B have the same first and last name. Patient A procedure report was written on a document with Patient B's full name and full SSN. This erroneous report was given to Patient A who discovered the…

Outcome: Patient A's report was corrected and verified. Patient B is deceased and a Notification Letter was mailed to the next of kin.

Issue: Patient A received a letter from his physician regarding an update on his condition and to notify him to schedule an appointment. In the same mailing envelope Patient A also received Clinic Progress Notes from Patient B's record. That progress…

Outcome: The Privacy Officer has notified the Ambulatory Care Supervisor of this incident and VA staff responsible for mailing patient information have been reminded that we are all responsible for protecting the privacy of our patients information and to take the…

Issue: The Release of Information (ROI) clerk mailed a completed VA form 5345 (Request For and Authorization To Release Medical Records) for Veteran A to Veteran B. The form contained Veteran A's name, and full SSN. Update: 09/26/12:Due to full SSN…

Outcome: Information was returned. Employee was educated and disciplined. Credit monitoring was mailed out.…

Issue: On September 1, 2011, a funeral home sent a fax to the Marion Release of Information (ROI) clerk for a copy of a DD-214. The ROI clerk faxed a DD-214 and a Honorable Discharge paper to the funeral home for…

Outcome: The supervisor will review all FOIA-PA cases for the next 90 days prior to the ROI clerk releasing anything and review 10% of all releases per month for the next fiscal year. The supervisor will meet with the ROI clerk…

Issue: On 09/20/12, An employee had a locking bag with confidential documents fly out of her vehicle trunk. After dropping off labs at the Grand Rapids CBOC, she placed the locking bag into her trunk and closed the trunk. As she…

Outcome: Bag has not been recovered, Credit monitoring letters have been sent to the Veterans involved. It has been requested that all bags are labeled with contact information for the VA Medical Center.…

Issue: The Regional Office contacted me about a document that was in the Claim folder. The Privacy Officer stated that the document in Patient A's record was his, but on the backside of the page was full name and last four…

Outcome: Information was retrieved. Staff were educated. Notification letter was mailed.…

Issue: A request for Outpatient Services which contained requested services to be rendered for Veteran A was sent to Veteran B. Update: 09/17/12:Veteran A will be sent a notification letter.…

Outcome: The information was returned to the facility. Staff members were educated on the current policies and handling of sensitive information.…

Issue: A married couple who are also Veterans were also VA employees. One worked at one CBOC, and the other worked at a nearby CBOC. The wife was killed in a fluke accident off duty. Employees accessed the husband's record in…

Outcome: The employees that were found to have accessed the record, have been educated and sanctions were done. We ask that no notification be sent to the spouse as it could affect more harm than good as no employee looked at…

Issue: Veteran A was in VANIHCS emergency room and was sent to a community hospital for treatment. A nurse handed the Veteran A a copy of his emergency room nursing discharge note. Along with his note was an emergency room nursing…

Outcome: The Emergency Room Nurse Supervisor met with all ER Nursing staff and mandated that upon returning to the exam room with the printed discharge note, the staff again verify the patient identifiers (name and date of birth) with the Veteran,…

Issue: A test results notification letter was sent to a Veteran A. Within his envelope was Veteran B's test results notification letter. The information in the letter included Veteran B's full name, mailing address, and lab results. Veteran A is returning…

Outcome: The Supervisor indicates the test letter notifications are printed in the mailroom, then folded and inserted into an envelope by a machine. The department is looking at new equipment with capabilities to print bar codes on letter and envelope to…