Desert Pacific Healthcare Network (VISN 22)

Issue: Veteran A and Veteran B received switched medication packages, via mail. The package contained the correct paperwork just the Prescription bottles were switched. PII included name and type of medication. Update: 01/06/12:Two Veterans will be sent a letter of notificaiton.…

Outcome: Supervisor verbally counseled the technician regarding privacy procedures. Notification letters mailed on January 5, 2011 and uploaded.…

Issue: Veteran A received a medication bottle for Veteran B via mail. Update: 01/04/12:Veteran B will be sent a notification letter.…

Outcome: The privacy Offcier was unable to determine which Pharmacist created the error; all employees reminded to check prior to mailing. Notification redacted letter uploaded; mailed January 4, 2012.…

Issue: On 12/30/11, the Administrative Officer for Compensation and Pension contacted VBA to check on the receipt of records shipped on 12/16/11. VBA did not receive the three boxes and 1 package containing 17 Veteran medical records shipped via UPS. VA…

Outcome: Was not VA fault but we will offer credit protection. Credit monitoring letter uploaded.…

Issue: Upon discharge, Veteran A received Veteran B's inpatient discharge note. Note contained full name, full SSN, medical information, and DOB. Update: 01/04/12:Veteran B will be sent a letter offering credit protection services due to full name, full SSN, DOB and…

Outcome: Employee admitted to not verifying Veteran information prior to providing the paperwork to the wrong Veteran. Supervisor verbally counseled employee and is working with Human Resources to conduct a written counseling. Redacted credit monitoring letter uploaded and mailed on January…

Issue: Veteran A returned a billing statement of Veteran B with the same name and same address to the Health Revenue Center (HRC). Update: 12/06/11:Veteran B will be sent a notification letter due to PHI being disclosed.…

Outcome: PO have notified the billing department supervisor of the mistake; corrected the address of the Veteran; and are sending a notification letter to the Veteran whose information was disclosed.

Issue: Patient A was provided with Patient B discharge papers. Patient B's full SSN, first name, demographics, and medical information was exposed. Update: 02/10/12:Veteran B will receive a letter offering credit protection services.02/24/12:After further review, Patient A had it for less…

Outcome: Staff was retrained.

Issue: A Nurse Assistant found a dietary listing with names and date of birth on 32 patients sitting on top of a trash can near a second floor elevator. The listing was found on 11/23/11 and given to the supervisor, however…

Outcome: A food service worker accidently left the listing on the cart with the food trays for inpatients. By the time of her return for the cart, the listing was lost near the elevators. The listing was left unattended for approximately…

Issue: A VA employee placed a form 522 into a frank sealed white envelope. The employee intended to place the envelope in a U.S. Government Messenger Envelope for internal mailing to medical records. It was mailed by accident to the U.S.…

Outcome: The VA employee intended to put the sealed frank envelope into an inter-departmental delivery envelope for delivery by internal means via VA mailroom employees to medical records for filing. The mailroom employee scanned the stack of envelopes but only looking…

Issue: On 10/18/11, a Pulmonary & Critical Care Fellow removed patient records (Cardiopulmonary Exercise Test Report Worksheet and the Pulmonary Exercise Laboratory) from VA Long Beach. The records were lost at a University of California, Irvine conference room. On the Pulmonary…

Outcome: On 11/9/11 the Privact Officer conducted an interviewed with the service chief to get all the facts surrounding the incident. The Supervisor and Service Chief has counseled and educated the members of their staff regarding the removing of patients records…

Issue: Following a Veterans Medical Research Foundation (VMRF) study intervention, a Without Compensation (WOC) Research Assistant turned in the study data forms to the co-investigator, however he inadvertently took the study compensation form with him in his backpack. The backpack was…

Outcome: The person involved the incident has been being requested to go through the training again and the new process are being put into place. The PI submitted the an action plan to the PO with the steps they are taking…