Rocky Mountain Network (VISN 19)

Issue: Veteran B received medications intended for Veteran A in the mail from the Sheridan VAMC. He has been instructed to return the medications to the clinic where he receives his care. Update: 05/21/12:Veteran A will be sent a notification letter.…

Outcome: The pharmacy continues to review their mailing processes and the pharmacy tech that mismailed this medication will receive verbal counseling and review the privacy training video.

Issue: Veteran A picked up a prescription at the Pharmacy window then went back to a group session. The Veteran opened his prescription bag and found another Veteran's medication information sheet enclosed. Veteran A handed the medication info sheet to the…

Outcome: Recommendation:Education for mishandling/mismailings requested be added to Staff Agenda.

Issue: An auto populated SF1199A direct deposit form was sent out to be filled in by Fee Basis providers. The form auto populated with a current employee's name, SSN and Home address. Update: 05/09/12:Employee A will be sent a letter offering…

Outcome: HR department retrieved a new SF1199A direct deposit form without auto populated information.

Issue: Veteran A receoved his own medication and paperwork in the mail and the paperwork for Veteran B. No actual medications were sent to the wrong person. Veteran A is returning the paperwork to the pharmacy assistant chief for disposal. Update:…

Outcome: Pharmacy mailing procedures were reviewed by assistant pharmacy chief with the pharmacy tech.

Issue: Veteran A came to his appointment and said he received Veteran B's lab results along with his letter. He turned it in to VA staff who turned it over to the Information Security Officer. The lab results contained veteran B's…

Outcome: Recommended Mismailing topic be included for the MSA monthly meeting.

Issue: Veteran A received Veteran B's medications at the pharmacy window. As soon as he discovered the mistake he brought the medications back to the pharmacy and they were destroyed. The information at risk included Veteran B's name and medication information.…

Outcome: The pharmacy staff member received a verbal counseling and will review the privacy video.

Issue: A Release of Information (ROI) clerk added Fee Basis materials for the scanning department to an outgoing ROI request. ROI recipient returned materials relating to Fee Basis Veteran to the Privacy Officer. Update: 04/23/12:The Veteran will be sent a letter…

Outcome: Employee removed from position and reassigned.

Issue: An employee admitted to the patient that she had taken it upon herself to access his medical records, prior to a date with the patient, for her own curiosity. The 2nd person was under a contract and had notified a…

Outcome: Employee was issued a reprimand for accessing this Veterans records inappropriately and reminded again of the importance of protecting our Veterans privacy rights. The other accesses were definitely a "need to know" basis for treatment purposes.…

Issue: Veteran A brought documents to the person at the check in desk that had been given to him at an appointment several days earlier. He was upset because there was a diagnosis on the routing slip that he had never…

Outcome: Re education has been provided to the involved staff. We were unable to determine when the actually breach occurred, but we believe that the information was given during the visit with the provider. The processes for check-out have been reviewed…

Issue: A patient advocate received a complaint from Veteran A that a VA Employee was accessing Veteran A's sensitive record and sharing medical information with others. Update: 04/13/12:The Privacy Officer (PO)states that she believes that the inappropriate access occurred. Veteran A…

Outcome: 4/18/12 PO spoke with Supervisor to see if employee had been interviewed. Supervisor will send me an update via email. Supervisort interviewed 5 MSAs who access sensitive record, all had valid reasons for access the Veteran's record. Sent an email…