Rocky Mountain Network (VISN 19)

Issue: VA Employee A found a document left on a printer for Employee B. It was the performance appraisal for Employee B.The performance appraisal is not protected under Privacy Act or considered PHI, however, OPM rules govern disclosure of employee performance…

Outcome: Education to RN manager to share and distribute to staff.

Issue: Veteran A's prescription sent by the Meds By Mail program sent to Veteran B. The informaiton disclosed included Veteran A's name and type of medication. Update: 11/25/11:Veteran A will recieve a letter of notification.…

Outcome: Meds by Mail supervisor contacted and reeducation has been completed.

Issue: Medications were prepared for 2 patients with the same name and the medication for Veteran A was passed to Veteran B. When Veteran A came in to pick up his medications the mistake was discovered. Veteran B was called and…

Outcome: The pharmacy staff is putting together a team to evaluate all processes within the outpatient pharmacy department to minimize the potential for future breaches. Unfortunately, there has been no specific trends regarding specific staff or processes that have led to…

Issue: During the discharge process a patient's discharge instructions were erroneously entered in the wrong patients electronic health record. When the provider printed out the instructions, they had the wrong patients full name, full SSN and DOB. This error was not…

Outcome: Involved staff provided with remedial training and awareness for attention to detail.

Issue: A phone call was received on October 20, 2011 informing a pharmacist that a Veteran who resides at the Wyoming Veterans Home in Buffalo would be on pass to Arvada, CO visiting relatives. It was requested that his medication be…

Outcome: Sheridan VAMC is looking at processes, and have provided education to staff to ensure that documentation takes place in CPRS regarding the request and who it was requested by.

Issue: Thirteen (13) Outpatient Routing Slips from the Neuro Clinic were found in Smoking Shelter outside the facility. Update: 10/21/11:Letters offering credit protection services will be sent to 13 Veterans due to full name and DOB being disclosed.…

Outcome: Employee identified through investigation. Supervisor notified of incident. PO recommended appropriate action be taken. Supervisor informed PO that on 10/31/11 action was taken. Notification letter signed by Medical Director see attached form. And letter sent out on 11/3/11

Issue: The Health Information Management Service (HIMS) Chief called the Information Security Officer (ISO) and asked the ISO to mark a patient record sensitive. The ISO marked the record. The HIMS chief called back and explained that she had just met…

Outcome: HIPAA/Privacy training was provided to all Pharmacy staff which addressed specific requirements and the expectations of 100% confidentiality of information obtained while on duty at this facility. Full investigation was completed and recommendation of administrative action provided to the Pharmacy…

Issue: Veteran A received Veteran B's medications at the Pharmacy window; this occurred on 10/07/2011. As far as the Information Security Officer (ISO) knows this was discovered on 10/12/2011 and reported to leadership and the ISO on 10/13/2011. The Pharmacy is…

Outcome: The Pharmacy is already working on how to resolve these types of issues. The employee who issued the medications has been counseled.

Issue: Received call from a secretary at the Regis University that PHI was faxed to her fax number. Three different veterans information was faxed about 100 pages. No fax coversheet was used and information was retreived by the Regis personnel and…

Outcome: On review of data fax the correct number of Veterans involved is 33 not 3. On investigation specific employee could not be identified so education from PO will be provided to the entire staff on the appropriate use and safeguards…

Issue: VA Employee A faxed Veteran Bs lab and two radiology reports to the wrong number. The intended fax was to go to Campbell County Memorial Hospital with a prefix of 688 but instead the employee dialed 684 and faxed to…

Outcome: The mis-faxed information was destroyed. Also the information was faxed to the correct number.