Desert Pacific Healthcare Network (VISN 22)

Issue: A Veteran became unmanageable and created a conflict which required VA Police to escort the Veteran from the clinic. A clerk provided the Veteran's wife with his paperwork prior to leaving the clinic. The Veteran's wife returned a document back…

Outcome: Incident did not happen on 10/24/11 as previously thought. On 10/18/11 at 8:05 am VA Regional Office faxed Veteran A benefit certification letter to the HUD-VASH. Veteran B HUD-VASH appointment was at 9:37 am; Veteran B Case Manager printed paperwork…

Issue: An Environmental Management Services (EMS) employee found a plastic bag containing a variety of cards and patient labels with names, social security numbers, etc. Update: 10/03/11:The bag was located at 7 PM, Friday, September 30 in a hallway in the…

Outcome: Privacy Officer has discussed the issue with the Supervisor and staff will be re-trained in proper handling of protected information.

Issue: On 09/14/11, an Environmental Management Service (EMS) worker sent an email containing patient names and room numbers over unsecured email, using both his VA and personal email, to several other VA employees. On 09/27/11, this worker then wrote a petition…

Outcome: The employee has been notified by the Privacy Officer that no patient information may be sent outside VA and no patient information may be sent internally without using PKI. In addition, the employee has been advised to use Vista email…

Issue: A VA employee working in the clinical area corresponded with another government agency to complain about her work experience at this medical center. Included in the complaint were references to four (4) patients including their full last name, last 4-digits…

Outcome: HR IS WORKING WITH SUPERVISOR RE: POSSIBLE DISCIPLINARY ACTION.

Issue: On 09/14/11, Veteran B called to report receiving Veteran A's prescription. Veteran B can identify Veteran A's last name, not social security number on mailing package. Update: 09/16/11:Veteran A will be sent a notification letter due to Veteran A's PHI…

Outcome: Inpatient and Outpatient Pharmacy staff has been informed of this incident. Staff have been informed to double check prescription numbers on bottle to match prescription number on printed paperwork and not rely on just name of medication.

Issue: An Access Log Report of employees that accessed Veteran A's records was sent to Veteran B who returned it. The written request by Veteran A did not have an SSN and the ISO ran a report for the incorrect Veteran.…

Outcome: The employees are aware of the mistake and will take precautions by ensuring the SSN is submitted with every new request for a copy of the access log report.

Issue: Veteran A reported on a Patient Comment/Safety Concern Report Form that while checking in on Sept 7, 2011 @ 2:35pm, a contract janitorial man stopped behind the check-in clerk and stared at the monitor. The clerk turned toward the janitoial…

Outcome: Upon investigation, the contract janitorial employee was near the computer at the time of incident to empty the trashcan located under the desk. The VA employee did not mitigate the situation because he felt there was no disclosure as he…

Issue: Patient A's advanced directive was inadvertently placed in Patient B's medical record. This advanced directive was printed out and given to Patient B. Patient B (who recieved the copy in error) was informed of the error and been instructed to…

Outcome: The private information was returned to the VA and the employee who self reported, will take additional care with the patient information she handles daily. A credit monitoring letter was sent to the patient.

Issue: At 3:45PM The ISO received a call from a VA Employee, stating that she left her document (Patient medical record) and other documents in her office this morning . After returning this afternoon she found out that the documents were…

Outcome: The supervisor of the nurse email to explained as: What type of documents were misplaced- procedure flow sheet, universal protocol checklist, discharge instructions, driver verification, call back sheetNames and last 4 of ssn of patients affected: only one patient, MXXXX…

Issue: On 08/22/11, a VA employee found two patient stickers and an armband with all the patient information on it. Both the armband and sticker were found in the stairwell outside of the 4th floor. Update: 08/23/11:Two (2) Patients will be…

Outcome: Stickers found in area of Operating Room --- Operating Nurse Manger re-educated her staff on the importance of patient safety regarding protecting PII