Rocky Mountain Network (VISN 19)

Issue: Veteran/VA employee opened his mail to discover two other Veterans letters included with his. The letters were appointment reminders. Update: 04/29/13:Veteran A and B will be sent a notification letter.06/05/13:This was determined to be HITECH reportable by VHA Privacy Office.…

Outcome: Employees were reminded on the importance of double checking work and only putting one patient per envelope.

Issue: The medication for Veteran A was mailed to Veteran B. Update: 04/29/13:Veteran A will be sent a notification letter.06/10/13:This was determined to be non-HITECH reportable by VHA Privacy Office.…

Outcome: The Pharmacy Outpatient Program manager reviewed processes and procedures.

Issue: A bio-hazard bag was found in an inpatient, locked, dirty utility room over the weekend. It looked like someone had emptied a sharps containers from 4 of the inpatient wards into this bag and then went through it looking for…

Outcome: 5 Notification letters and 2 credit monitoring letters were sent out to the patients involved. Redacted letters were put in the attachments section.The housekeeping Manager will be providing education to his weekend contract employee's on handling and disposal of the…

Issue: An employee was being treated at the Hospital when the treating employee took a phone call with another provider and discussed another patient's medical information without leaving the room in front of the employee/patient being treated. Update: 04/10/13:Patient B will…

Outcome: Employee retook privacy and information security training.

Issue: On Sunday,03/03/13 at 3:24 PM, Patient A checked in to the Sheridan VA Health Care System. At the time of check-in, Patient A received the document "Verification of Patient Demographic Data" for Patient B. Patient A went to his/her lodging…

Outcome: The responsible staff members were required to review check-in procedures and re-take the yearly privacy training.

Issue: Up to 66 patients may have received another Veteran\xe2\x80\x99s Request for Outpatient Services form that included the Veterans' names, address, date of birth, and last four of their social security numbers. A volunteer was assisting a VA Employee with creating…

Outcome: Letters were sent out and training was provided to employee.

Issue: A full set of medical records was mailed to Veteran A for Veteran B and vice versa. The outside of the envelopes and the contents on the envelopes were properly addressed in the Release of Information (ROI) office, but the…

Outcome: The mail clerk's supervisor was informed of the error and will be providing a statement to the privacy office indicating what action will be taken to prevent this from occurring again.

Issue: During the Environment of Care Rounds on Mountain View Living Center (Nursing Home Unit), the Information Security Officer (ISO) entered the old South Nurses station. This station is used by staff on an infrequent basis. The station has counters on…

Outcome: The nursing home staff has implemented a process that in their regular unit rounding that the door is shut, locked, and that it is a document free zone. This will occur x8 times per 24 hours.

Issue: During the Environment of Care Rounds on Mountain View Living Center (Nursing Home Unit), the Information Security Officer (ISO) entered the old South Nurses station. This station is used by staff on an infrequent basis. The station has counters on…

Outcome: The nursing home staff has implemented a process that in their regular unit rounding that the door is shut, locked, and that it is a document free zone. This will occur x8 times per 24 hours.

Issue: During the Environment of Care Rounds on Mountain View Living Center (Nursing Home Unit), the Information Security Officer (ISO) entered the old South Nurses station. This station is used by staff on an infrequent basis. The station has counters on…

Outcome: The nursing home staff has implemented a process that in their regular unit rounding that the door is shut, locked, and that it is a document free zone. This will occur x8 times per 24 hours.