Rocky Mountain Network (VISN 19)

Issue: Printed documents were left out in a public lobby with patients PII unsecured. Update: 02/01/13:Due to full SSN being exposed, Veteran A will be sent a letter offering credit protection services.…

Outcome: 2/6/13 - Employee will be receiving a written counseling - Please close this note

Issue: Medication paperwork of Veteran A was mis-mailed with Veteran B's paperwork. Veteran B received his correct medication and paperwork, and also received the same medication paperwork of medication for Veteran A. Update: 01/16/13:Veteran B will be sent a notification letter.…

Outcome: Medication paperwork was returned to the VA, and education was provided through the pharmacy department on the need to double check information prior to mailing out medications with accompanying paperwork.

Issue: Veteran A brought in a Lab letter that they had received for Veteran B in the mail along with their own letter. Update: 01/14/13:Veteran B will be sent a notification letter.…

Outcome: Discussed and provided education to employees on importance of Privacy for patients.

Issue: Veteran brought into CBOC a letter addressed to a different patient which was included in mailing Veteran received about her personal care. Update: 12/19/12:Veteran B will be sent a notification letter.…

Outcome: Associate Chief of Staff to speak with staff who are responsible for mailing appointment and lab result letters.

Issue: Veteran A requested copies of his medical records. When they arrived the envelope included some of his medical records as well as a CD that belonged to Veteran B. Update: 12/14/12:Due to full name and date of birth being exposed,…

Outcome: HMS Supervisor established new process. Verify patient information on all CDs from other departments prior to ROI mailing medical information.…

Issue: A deceased Veteran's medical records were requested by a family member. The records were requested back from the Federal Record Center. The tracking number shows the records were delivered to the VA however, no one can find the records. We…

Outcome: The process was changed to a centralized pickup and drop off for package being delivered and picked up.

Issue: A Community Based Outpatient Clinic received a hand written note from Veteran A stating he received his lab results and Veteran B's lab results. He returned the mis-mailed lab letter with his note to the Community Based Outpatient Clinic (CBOC).…

Outcome: Requested Nurse Manager to add the importance of quality assurance when mailing letters to Veterans, ensuring that we are not violating Veteran's privacy by exposing information to others who do not have a need to know. Privacy Officer offered to…

Issue: The Pharmacy mismailed out medication. The mailing contained wrong mailing address for the Veteran. Protected Health Information disclosed: Full name, Medication Label. Update: 11/21/12:One Veteran will be sent a letter of notification.…

Outcome: The pharmacy technician has been counseled. A triple check is required prior to relabeling and address label. This error was also discussed at the pharmacy staff meeting and emphasis was put on following procedures to include the Triple check…

Issue: Veteran A received copies of medical records pertaining to Veteran B with copies of her own medical records. The medical records contained medical information as well as name, date of birth, and full SSN. Update: 10/26/12:Veteran B will receive a…

Outcome: Retrieved document and resent another copy of the Release of information (ROI) request to the Veteran. ROI supervisor reminded the ROI clerks of the importance of double checking the address before sending out requests.

Issue: Veteran A received lab results in mail. The envelope that contained lab results also had lab results for Veteran B. Veteran B's full SSN was disclosed. Update: 10/16/12:Veteran B's will be offered credit protection services.…

Outcome: 10/18/12 Spoke with the volunteer at Missoula CBOC about the importance of checking to make sure the lab results are placed in the correct envelope for the patient whose name is on the lab report. Explained the process when Veterans…