Phoenix VA Health Care System

Issue: Veteran B received medications intended for Veteran A from outpatient pharmacy pick-up window. Veteran B realized error at home and reported to pharmacy by phone. Pharmacy sent Veteran B a pre-paid return envelope and recovery is expected early next week.…

Outcome: 08/02/13: Veteran A will be sent a notification letter.…

Issue: 7/24/13, routine audit by Research Compliance Officer showed five informed consent forms for a research study were not scanned to the respective patients' charts. Three were immediately found in a locked cabinet by the Clinical Research Coordinator for the study,…

Outcome: 07/25/13: Due to full SSN and medical information being disclosed, Patient A will be sent a letter offering credit protection services.…

Issue: On, 7/23/2013, Pharmacy Supervisor reports to Privacy Officer (PO) that Veteran B was discharged yesterday with her home medications (brought in from home) and also received Veteran As home medications. Veteran B is a Mental Health Intensive Case Management (MICM)…

Outcome: 07/19/13: Veteran A will be sent a letter offering credit protection services.…

Issue: On 07/17/13, the Administrative Officer (AO) at a Community Based Outpatient Clinic (CBOC) reported to the Privacy Officer (PO) that Veteran B received a letter by mail intended for Veteran A. The letter was mailed by the CBOC to Veteran…

Outcome: 07/19/13: Veteran A will receive a letter offering credit protection services.…

Issue: Today, 06/13/13, the Pharmacy Supervisor reports to Privacy Officer (PO) that yesterday evening his staff determined that a medication and educational documents for Veteran A were provided to Veteran B on 06/11/13. This was discovered late yesterday, 06/12/13, when Veteran…

Outcome: 06/13/13: Veteran A will be sent a notification letter.…

Issue: On 5/23/13, the Principal Investigator (PI) of research study reported that two photocopied informed consent forms that had previously been sent for scanning to CPRS in December, 2012 had not yet been scanned to the patients' charts. PI stated the…

Outcome: 05/24/13: Both Veterans will be sent letters offering credit protection services. 05/31/13: One of the documents was found in the office of the intended recipient. Only one Veteran will be sent the credit monitoring offer.…

Issue: On May 17, 2013 the Pharmacy Supervisor reported to the Privacy Officer (PO) that Veteran B turned in three medications in two bottles. They were received by mail on May 16, and were intended for Veteran A. The medications were…

Outcome: 05/20/13: Veteran A will be sent a letter of notification. 06/05/13: This was determined to be non-HITECH reportable by VHA Privacy Office.…

Issue: Today, 5/9/2013, Pharmacy Supervisor reports recovery of 3 Veteran Rx's, mailed erroneously to Veteran B. Veteran B returned them today to check on his own address. Pharmacy supervisor found that Veteran A's address had been changed, then corrected but not…

Outcome: 05/09/13: Three Veterans will be sent a HIPAA notification letter. 06/05/13: This was determined to be non-HITECH reportable by VHA Privacy Office.…

Issue: On 05/06/13, a supervisor informed the Privacy Officer (PO) that Veteran B presented to an outpatient clinic today with a paper appointment reminder for Veteran A. The supervisor identified the root cause. Apparently the scheduler was in Veteran As chart…

Outcome: 05/06/13: Veteran A will be sent a notification letter. 06/05/13: This was determined to be HITECH reportable by VHA Privacy Office.…

Issue: On 05/01/13, the Regional Office (RO) Privacy Officer (PO) reports to the VAMC PO that Veteran A provided her with Veteran Bs operative report along with his medical records for claims purposes. This was discovered in the claims file by…

Outcome: 05/02/13: The family of Veteran B will receive a next of kin (NOK) letter.…