Orlando VA Medical Center

Issue: Inside Veteran A's pharmacy bag was a medication list for Veteran B. The bag arrived at Veteran A's house on Jan. 8, 2014. Since Veteran A had an appointment today, he chose to inform the clinic staff of the error.…

Outcome: 03/11/14: The Incident Resolution Team has determined that Veteran B will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: Veteran A received Veteran B's medications in the same medication bag, mailed from the Outpatient Pharmacy. Pharmacy is sending Veteran A a UPS bag to retrieve the medications. Pharmacy looking into how the medications could have been cross-bagged.…

Outcome: 03/07/14: The Incident Resolution Team has determined that Veteran B will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: Veteran A received Veteran B's treatment records in the mail. Veteran A returned the records to his Veteran Service Officer, who in turn mailed to local VBA Outbased Office, who in turn contacted their Regional Office Privacy Officer (PO), who…

Outcome: 01/08/14: The PO got the records yesterday and it appears that there was a total of approximately 60 pages of protected health information (PHI) containing Veteran B's full name, SSN, DOB, and assorted medical information (i.e. Progress Notes, Consults, C&P…

Issue: Besides his own paperwork, Veteran A received Veteran B and Veteran C's medication paperwork in two separate mailings, one from his main pharmacy, and the other from a nearby Outpatient Clinic (OPC). Veteran A's adult daughter returned the incorrect paperwork…

Outcome: 10/22/13: Veteran B and C will be sent a notification letter.…

Issue: Veteran A picked up his pharmacy bag and noticed the attached label was for Veteran B (same last name, different first name). He immediately returned the unopened bag to the pharmacy. The bag contained his medication (Veteran A) , but…

Outcome: 10/10/13: Veteran A will be sent a notification letter.…

Issue: A medication bag for Veteran A was mis-mailed to Veteran B who also has same first, middle, and last name. Veteran B called the pharmacy when he did not recognize his doctor's name. Veteran A's name, address, and meds was…

Outcome: 10/10/13: Veteran A will be sent a notification letter.…

Issue: Veteran A was given Veteran B's medication list when Veteran A visited the pharmacy for pick-up. The medication list also showed two future appointments for Veteran B. Unfortunately, Veteran A covered up Veteran B's name with a sticky note so…

Outcome: 09/30/13: The medication list was returned to the facility PO on 10/01/13 by mail. Upon examination, the PO confirmed that no SSN was printed. However, a MM-DD-YYYY was machine printed across the top of the form, but not flagged as…

Issue: Veteran A was handed the appointment list for Veteran B and didn't discover the error until after he arrived home. Both Veteran A and B have the identical last names, same last four SSNs, and same DOB, except year. Veteran…

Outcome: 09/19/13: Veteran B will receive a HIPAA letter of notification.…

Issue: In addition to his own lab results, Veteran A received Veteran B's test results in the same envelope. Besides the lab results, the letter contained Veteran B's full name and mailing address. Veteran A returned the letter and envelope to…

Outcome: 09/09/13: Veteran B will be sent a HIPAA notification letter.…

Issue: Veteran A received a cover letter but the attachments were for four different Veterans. The attachments consisted of VA Forms10-7079, "Request for Outpatient Services" authorizations. Veteran A returned the forms to the nearest Community Based Outpatient Clinic (CBOC) and will…

Outcome: 08/09/13: Four Veterans will be sent a notification letter, as their names and medical information were disclosed.…