Rocky Mountain Network (VISN 19)

Issue: Employee A mis-typed the phone number of a faxed Oxygen prescription order. Faxed order was sent to a Diesel Service shop instead of intended contractor. A Veteran that worked at the shop received the fax and telephoned the VA. PHI…

Outcome: Provided education to employee on importance of double checking information prior to sending sensitive information out.

Issue: Veteran A received Veteran B's appointment letters in the mail. Veteran A brought the two upcoming appointment letters to the clinic. The letters were forwarded to the Privacy Officer. Update: 07/30/12:Veteran B will be sent a HIPAA notification letter. Veteran…

Outcome: PO reviewed mail handling procedures with individuals who are mailing appointments.

Issue: 3 blood tubes, for one patient, were found this morning by a VA employee in a womens restroom. The labels contained the patients full name and full SSN. The tubes were left by a VA employee. Update: 07/27/12:Patient A will…

Outcome: Employee was issued a written counseling. A credit monitoring letter was sent on 7/30/12. 9/28/12…

Issue: A Contractor responsible for scanning eOPF files copied Employee A's information into Employee B's eOPF files. Employee B found the information and reported it to Human Resources (HR). The information at risk included Employee's A's name, full SSN and employment…

Outcome: Materials removed from Employee's eOPF file and sent to correct file.

Issue: The contract scanning group scanned Employee A's performance appraisal into Employee B's eOPF file. The appraisal contained Employee A's name, full SSN and employment information. Update: 06/26/12:Employee A will be sent a letter offering credit protection services.…

Outcome: The inappropriate record was removed from the eOPF file by local HR.

Issue: Veteran A received Veteran B medication. Veteran A returned prescription packet back to pharmacy. Update: 06/21/12:Veteran B will be sent a notification letter.…

Outcome: Pharmacy Chief will continue to have mis-mailing topic on the staff meeting agendas.

Issue: The Clinical Pharmacist lost 7 of his paper inpatient flow sheets. These papers contained the patients full name, full SSN, DOB, diagnosis, labs and meds of these patients. The Pharmacist retraced his steps from yesterday, but did not have any…

Outcome: 6/15/12 - The Clinical Pharmacist informed the PO that all of the PII had been removed from these documents and they will be using a code instead.6/27/12 - Credit Monitoring letters were sent out - Redacted letter uploaded.

Issue: Medications for 2 different Veterans (Both controlled substances) were mailed to the incorrect patient. Patient A got Patient B meds and vice versa. Update: 05/29/12:Both Patients will be sent notification letters due to PHI being disclosed.…

Outcome: The supervisor indicated that he had counseled the individual that caused the incident and then had department training - RE: QA and take the time to verify outgoing meds matched the addressed packages. Supervisor had addressed this situation and contacted…

Issue: Veteran A had Veteran B's medication guide in with his medication. The guide contained Veteran B's name and medication information. Update: 05/30/12:Veteran B will be sent a notification letter due to PHI being disclosed.…

Outcome: The PO requested Pharmacy Chief to discuss mis-mailings at Staff Meeting.

Issue: Veteran A was given Veteran B's medication list at check-in. He was taken back to the triage nurse and noticed that the medications on the list were not his. He then looked at the name on the list and realized…

Outcome: The process for medication reconciliation at check in was reviewed with the new staff member. Education was provided as requested by supervisor.