Rocky Mountain Network (VISN 19)

Issue: A Veteran A picked up his prescriptions at Fort Harrison Pharmacy. The Veteran did not realize there were two prescriptions, his and Veteran B's, in his bag until he got home. Both prescriptions had the same last name. A pre-paid…

Outcome: 10/17/12 Rec'd email response from Pharmacy Chief stating Script-pro has a known deficiency and VA Pharmacy is communicating with the vendor. Additionally she will address this issue and request that the Pharmacy staff ask the patient "I see you have…

Issue: During the Environment of Care Rounds on October 10, 2012, the Facility Information Security Officer found on a printer eight appointment letters, six dated October 4, 2012 and two dated October 9, 2012. This printer is part of a computer…

Outcome: The Printer was moved from that location to a more secure location behind a locked door.

Issue: Provider asked a Patient to return his own routing slip to the Medical Support Assistant (MSA) for scheduling future appointments, and asked the patient to take another patient's routing slip and Med Rec forms to the MSA as well. Update:…

Outcome: Chief of Staff reeducated provider on issue.

Issue: Veteran A received Veteran B's medication in a bag full of his own medications. The Veteran destroyed the drug infomation sheet and turned in the medications to the pharmacy for destruction. Update: 09/24/12:Veteran B will be sent a notification letter.…

Outcome: The Pharmacy assistant chief reviewed procedures with all staff at a recent staff meeting in hopes of mitigating this type of disclosure breach. The entire staff has been cautioned about slowing down and taking the time to review all medications…

Issue: I received a call from a Home based Primary care nurse that was at a patients (Veteran A) residence. The Veteran A was called on the morning of 9/21/2012 by Veteran B that said that he had received Veteran As…

Outcome: The information was not able to be recovered. The facility will continue to provide training and awareness to employees about protecting sensitive information. Credit letter was sent out on 1/31/2013.

Issue: An employee left a book in a public restroom that had 2 patients' treatment notes stuffed under the cover. The treatment notes contained the patients' names, dates of birth , full SSNs and other medical information. Update: 09/20/12:It is not…

Outcome: 9/27/12 - Supervisor reminded all of her staff members about protecting our customers privacy in their monthly staff meeting.

Issue: Patient A reported to medical staff at an outlying clinic that he had received another patients information with a prescription he received from the Grand Junction, CO VAMC Pharmacy. Patient A provided the staff member with the box the prescription…

Outcome: Remedial training to be provided to all Pharmacy staff. Notification letter sent to affected Veteran.

Issue: The medications for Veteran A were mailed to Veteran B and the medications for Veteran B were mailed to Veteran A. It appears the Veterans had the same last initial of the last name. Update: 09/17/12:Both Veterans will be sent…

Outcome: Medications were retrieved and destroyed. Education was provided to entire pharmacy staff regarding procedures for dispensing medications at the window.

Issue: A provider handed three routing slips to Veteran A to take to the front desk. One slip was the Veteran's own slip. He handed all three slips to the clerk and said that the provider had asked him to bring…

Outcome: Provider reeducated by Chief of Staff.

Issue: Veteran A contacted the Privacy Office to inform that he received in the mail Veteran B's patient information along with his letter from the facility. The information that was contained in the letters were lab results, and x-ray results. Update:…

Outcome: 9/14/12 Privacy Office received back the information received from the Veteran. Some corrections were made to the type of data that was disclosed. The number of Veteran affected by the disclosure was also updated. Credit letters sent to Veterans on…