Desert Pacific Healthcare Network (VISN 22)

Issue: A VA Pharmacist intended to fax two controlled substance prescriptions for same Veteran to the Pharmacy at another clinic, but the fax machine sent it to the last faxed number used, which was a State Nursing Home. There is a…

Outcome: The pharmacist immediately noticed that the fax machine sent it to the wrong fax number and called the Nevada State Veterans Home, and staff agreed to destroy the documents. Notification letter mailed and uploaded on April 26, 2013.…

Issue: A travel clerk was faxing the list of patients who would need transportation the following day which is provided by a contracted service. After faxing the list, the clerk realized they had sent the list to the wrong number. The…

Outcome: The partial SSN has been removed from the list and training conducted with the staff to verify the fax number before hitting send. Attached a sample copy of the signed notification letter.

Issue: A Veteran provided copies of his x-rays and MRI images to be used in an orthopedic consult to obtain a second opinion on a medical condition. A review of the patients CPRS notes indicates that the images were viewed by…

Outcome: Training was conducted with the staff involved to emphasize the importance of protecting Veterans medical records and the proper procedures for routing physical records to be scanned into the electronic record

Issue: Veteran A received Veteran B's appointment listing. Information disclosed included full name and full SSN. Update: 04/15/13:Veteran B will be sent a letter offering credit protection services.…

Outcome: Unable to determine which employee disclosed the wrong document as the Veteran was unsure which clinic/department the appointment list came from. Credit monitoring letter uploaded and mailed on April 16, 2013.

Issue: A Veteran complained that a Mental Health employee left a detailed telephone message on his brothers answering machine outlining various Mental Health resources and that he could be referred to treatment for alcohol at another location. Update: 04/12/13:Veteran A will…

Outcome: The Chief of the Department emailed the individual and all of the staff with specific instructions and guidance not to leave any sensitive of health information on answering machines. A notification letter has been mailed to the patient.

Issue: Medical records were mailed to the wrong Veteran. Same last name, wrong Veteran. Update: 04/10/13:Veteran B will be sent a letter offering credit protection services.04/10/13:Update - Privacy Officer states that Veteran A claims his information was also exposed therefore Veteran…

Outcome: We have re-educated the Release of Information staff. We stressed the importance of quality control when dealing with medical records. Recommend that this ticket be closed. Credit protection letter has been mailed out. Will upload the redacted letter.

Issue: When a new drug used in the treatment of HIV was added to the facilitys formulary and e-billing system, the individual adding the medication failed to input the code identifying the medication as sensitive for the treatment of a 7332…

Outcome: Notifications sent and training held as well as a review of policies and procedures.

Issue: A Bravo pH medical device was lost. The Bravo pH is a capsule-based, patient-friendly test for identifying the presence of acid reflux in ambulatory patients over the course of several days. A nurse had placed a patient label on the…

Outcome: Policies have been reviewed and it was not part of the SOP to place the label on the device. The staff has been educated on proper procedures and labels will not be attached to the devices.

Issue: Veteran A received Veteran B's medication bottle intermingled with Veteran A's package via mail. The only personally identifiable information (PII) was Veteran B's name and medication information.. Update: 03/21/13:Veteran B will be sent a HIPAA notification letter.…

Outcome: PO unable to determine which employee mailed medication package. Notification letter mailed 3/21/13 and uploaded into PSETS.…

Issue: Domiciliary Veteran A's information, including full SSN, full name, date of birth, and home address, was placed on another Veterans B's bed by a VA employee. The information was returned by Veteran B. Update: 03/21/13:Veteran a will receive a letter…

Outcome: The Privacy Officer conducted an in-service training to the staff and the Chief of the Dom is taking further action.