Issue: Veteran Record reported missing from CLC. Name, SSN, and PHI were included in record. Update: 01/10/11:PO states CLC stands for Community Living Center (Nursing Home). The record has been missing since 03/23/10. The record is still missing. The Veteran will…

Outcome: Privacy Officer advised the Service Chief to create an SOP for the filing of the CLC records and retrain the nurses.

Issue: Pharmacy employee mis-mailed prescriptions to the wrong Veterans. Veteran A received Veteran B's prescription and vice versa. Veteran A called the pharmacy to report receiving wrong RX's. Veteran B was called by pharmacy and confirmed he had received the wrong…

Outcome: Appropriate management action has been taken. PO performed re-education to staff.…

Issue: During new provider orientation, medical coder inadvertently presented information on a Veteran and did not utilize "Test Patient" account. The encounter form presented included name, DOB and full SSN. The document was shown on screen, no physical document was distributed.…

Outcome: Appropriate management action has been taken. PO is scheduled to provide additional education at next staff meeting.…

Issue: Air Force personnel found VA outgoing mail in parking lot on an Air Force base with a joint VA and Air Force hospital. Nine unopened and sealed envelopes with patient name and address and two interoffice envelopes with eight Veteran…

Outcome: Eight credit monitoring letters sent; supervisor counseled employee on safeguarding sensitive information while conducting mail runs including reminding all employees in the department. Employees were did not properly transport sensitive information via interoffice mail was counseled on the proper method…

Issue: Veteran A received Veteran B's letter in addition to his own which included name and PHI. Update: 01/06/11:Veteran will receive a letter of notification.…

Outcome: Talked with provider, nurse and clerks from area that the letter came from. Need to double check for single letter included in each envelope.…

Issue: Employee A was witness to and reports that employee B improperly disclosed sensitive health information to another employee about a family member of employee A. Employee B was unaware that the patient being referred to was related to Employee A.…

Outcome: Supervisor counseled employee responsible for event.

Issue: Transitional Living Center (TLC) Activity Sheet was discovered in the TLC activity room by a VA employee. The paperwork was immediately reported to the Privacy Office and the paperwork was given to the TLC supervisor. The supervisor had the paperwork…

Outcome: Nursing Manager briefed all employees of their responsibilities for protecting sensitive information. Credit protection letters sent out this date. Recommend incident be closed.…

Issue: Veteran A received Veteran B's paperwork. Update: 01/07/11: Veteran B will receive a letter offering credit protection services since his full SSN and DOB was exsposed.…

Outcome: Document retrieved. Education provided to staff on verification process initiated by bene travel department. Credit monitoring ltr sent this morning. Please close ticket.…

Issue: A VA employee mis-faxed a Prosthetic Form to an incorrect fax number. The receiver notified the facility of this issue and provided the documents received. Update: 01/07/11:Veteran will receive a letter of notifciation.…

Outcome: Education and training to include being aware of and double checking the fax number prior to sending, was provided to the employee that was involved with this mis-faxed document.

Issue: A canteen employee found a copy of the Inpatient Roster in the canteen cafe and gave it to the Service Chief. The roster includes the patients' full name, SSN, DOB and PHI. Update: 01/11/11:There were seventy nine names on the…

Outcome: The Service Chief identified the employee responsible for leaving the list unattended and provided verbal counseling. The credit protection and notification letters were sent.…