Issue: Mis-mailed medication packet. Update: 01/25/11: Veteran will receive a letter of notification.…

Outcome: Meds retrieved from wrong Veteran. Redacted and signed notification letter sent to Veteran.

Issue: The Queens Medical Center requested copies of the entire medical record of a veteran patient of VA Pacific Islands Health Care System (VAPIHCS) on Oct 27, 2010. We made copies and mailed them on Oct 28, 2010. The patient reports…

Outcome: The ticket was turned into an incident after a search at the Queens Medical Center failed to turn up the copies sent from VAPIHCS. Credit monitoring was offered to the Veteran/patient. We've started tracking copies of records sent out of…

Issue: Med by Mail employee send a PT PII and PHI to another patient with the same first name and same last name. The information contained the PT full name, address, date of birth Update: 01/26/11:Patient will receive a ltter offering…

Outcome: Employee was instructed to verify the correct PT info was going to the correct PT before mailing

Issue: Department of Defense (DoD) Patient A received two prescriptions intended for Department of Defense (DoD) Patient B. Patient Bs name and type of medication were compromised. Patient A returned the package to the medical center and a replacement has been…

Outcome: The CMOP employee will be counseled and retrained in proper packing procedures.

Issue: Veteran A faxed the medical record medication list and discharge instructions of veteran B he received while on appt from his Primary care provider to the VISN office. PHI disclosed: Full name, full ssn, birth date, home address, home phone…

Outcome: Staff was provided education by Service and understands importance of correct patient identification. The letter went out in mail this morning. Please close ticket, thanks.…

Issue: Requestor faxed request to the outpatient clinic on 10/26/2010. Request stated that the request was for a workmen's compensation claim on behalf of the veteran's employer. ROI Clerk released copy of entire patient record to requestor on 11/8/2010. Patient contacted…

Outcome: All employees responsible for release of information will be required to review training material specific to the requirements for a valid authorization.Employee must sign that they have read and understand the material.

Issue: Complainant alleges his electronic medical record was impermissibly accessed by 2 VA employees in February and March of 2010. Filed complaint with HHS/OCR. Update: 04/22/11:The employee will be sent a notification letter.05/02/11:Upon further investigation, the disclosure involved the full SSN,…

Outcome: Disciplinary Action taken against two employees. Veteran/employee received response. HHS/OCR response provided on 1/25/11. HHS/OCR wants this complaint changed to a incident since it was determined that two employees impermissibly accessed their co-worker's electronic health record.…

Issue: During an audit of the study entitled: "Memphis VAMC: Nutrition Day 2010 in the United States," the Memphis VAMC Research Compliance Officer noted that informed consent for 9 study subjects were not obtained, i.e. Principal Investigator did not take the…

Outcome: PO met with Principal Investigator (PI) to explain the risk and financial cost of this breach in terms of credit monitoring, etc. PI has learned her lessons from this breach and has assured PO of her willingness to prevent such…

Issue: An ROI employee gave Veteran A the DD214 for Veteran B. When Veteran A was asked by the ROI employee, what he had done with Veteran B's DD214, he said he had thrown it in the trash. Update: 01/27/11:Veteran B…

Outcome: The employee was issued a written counseling and advised to slow down, and to take the time to ensure that any documents given to a Veteran belonged to that individual.

Issue: Patient A received her own records that she had requested. Patient B's records were also included. The PO is not certain what records were disclosed nor who was responsible. Patient A is to return the records to the PO. Update:…

Outcome: Responsible employee reminded to use caution when handling documents with PII/PHI