Issue: Clinical laboratory report of one veteran was mailed to another veteran by mistake. Name, SSN and PHI were released. Update: 01/11/11:Veteran will receive a letter offering credit protection services since his full SSN and DOB was exposed.…

Outcome: The ISO met with the staff and provided education

Issue: A physician reported that a residency folder is missing. Update: 01/18/11:After speaking with the PO she stated the DOB was exposed.The residency will receive a letter offering credit protection services.…

Outcome: No SSN on document. No breach. Physician knows to be more careful.…

Issue: Veteran A was given Veteran B's information. The document contained Veteran B's full name, date of birth, last four of the SSN, and telephone number. Update: 01/11/11:Veteran B will receive a letter offering credit protection services.NOTE: There were a total…

Outcome: The credit protection letter was mailed to Veteran B. The employees were re-educated on the guidelines for handling and/or disclosing PHI.…

Issue: Patient received the medication intended for his uncle. He noticed it was not his medication due to the types of medication and notified the Pharmacy. New meds were sent to the correct patient. Update: 01/11/11:Patient will receive a letter of…

Outcome: The resolution is that new meds were sent to the patient. Although the staff at this facility were not at fault, it has been identified that the USPS mis-delivered a medication package which had the same effects of a miss-mailed…

Issue: Patient A received two other veterans Prosthetic device requested notification letters inside his envelope. Patient A returned both letters to the Prosthetic department Update: 01/13/11:Two (2) Patients will receive a notification letter.…

Outcome: staff re-educated

Issue: Veteran A received mail that was intended for Veteran B. The appointment letter included Veteran B's name and partial SSN and clinic information. Update: 01/20/11:Veteran B will receive a letter of notification.…

Outcome: Veteran A will return the mailing to the Privacy Officer. The PO will conduct service level training with appropriate staff.Notification letter mailed to the veteran. Redacted copy sent to IRCT for ticket closure.

Issue: A veteran turned in to the Rapid City CBOC three hard copy records; they were the Standard Form 509 Medical Records progress notes from the Fort Meade (FM) Eye Clinic. The progress notes contained his own information plus the notes…

Outcome: Isolated honest msitake; Notification letters sent.

Issue: Endoscopy/biopsy specimen results delivered and signed for by a VA from FedEx Tracking on November 8, 2010 at 9:31 AM. Signed for by a VA employee, but unable to locate the results. Disclosed information included name, social security number, lab…

Outcome: Established policy and procedures for handling and disposition of specimen leaving and being received by the lab.

Issue: A DOM Technician allegedly provided DOM Resident A with the roster to show him his eligibility for DOM privileges (or lack thereof). The technician failed to secure it and Resident A retained the roster until yesterday, when Resident B (during…

Outcome: The importance of protecting private information of residents who are served in the program was discussed at the Dom Morning Report meeting In addition, the staff is engaged in discussions of observing for areas where private information might be at…

Issue: Veteran A believes that an unauthorized disclosure of his information (which he feels was inaccurate in addition to being disclosed without his authorization) resulted in his social security benefits being suspended. Documentation in the medical record does not support Veteran…

Outcome: The individual alleged responsible for this breach left VA employment sometime ago. "prior" to this incident being reported. Supervisor of dept. however has reiterated to staff in department, the need for patient privacy and the fact that it everyone's responsibility.…