Rocky Mountain Network (VISN 19)

Issue: Employee A reported that while reviewing lab results with Patient A via telehealth, the patient stated that the printout he had received from the clinic staff was that of Patient B. The printout was returned to clinic staff and Employee…

Outcome: Investigation completed by the Privacy Officer. It was determined that a VA employee had carelessly provided the wrong documents to the patient. The documents were returned to VA custody after a very brief time in the patient's possession while he…

Issue: patients with extremely similar first and middle names and identical last names had demographics cloned in CPRS due to improper check in process (ID verification). Result was patient B recieved Patient A demographics and patient A was contacted for scheduling…

Outcome: Proper check in and verification protocols initiated.

Issue: The VA was notified on 3/6/12 that on 2/24/12 the US Post Office delivered medication package to the wrong veteran. Veteran open package and took medications and then realized that it was not his medication package. Veteran contacted VA to…

Outcome: Education and awareness was provided to the pharmacy department on the error by the postal service. With this being an isolated incident, it was determined not to contact the postal service. however, the Medical Center is keeping a running active…

Issue: On 1/12/12 a Veteran received extra paperwork work with their medication packet that belonged to another veteran.PHI exposed: Veteran full name, medication decryption. The Veteran is just reporting it now. Update: 03/09/12:One Veteran will be sent a letter of notification.…

Outcome: Provided education and training to the Chief of pharmacy about the need to have written information that contains the Veterans health information returned to the facility for destruction. Pharmacy chief to educate and train staff on new procedure.…

Issue: Medications for Veteran A were apparently included in a package to Veteran B. It is unclear how it happened and an investigation is being conducted to determine where the medications were dispensed from. Update: 03/05/12:Veteran A will be sent a…

Outcome: Employee has been educated in proper mailing procedures and may receive further disciplinary action through Human Resources.

Issue: On 01/17/12, Patient A with similar last name received medication and a prescription for Patient B at the same time. patient A noticed the error and brought the incorrect medication back. Patient A did not take any incorrect medication and…

Outcome: Medication was returned within 30 minutes. Education and emphasis with the pharmacy chief on the importance of double checks in handing out medication at the window. Pharmacy Chief is also working with the pharmacy software vendor to find out why…

Issue: An employee found an unused inpatient wristband in a public smoking area with the patient's picture, full name, full SSN and date of birth. Update: 01/30/12:The patient will be sent a letter offering credit protection services.…

Outcome: Credit monitoring letter was sent to the Veteran - a hospital wide e-mail was sent to all staff explaining the incident and reminding them of the importance of protecting their patient's privacy.

Issue: An incorrect address label was put on medication packet and sent to the wrong Veterans. Information disclosed was Veteran B's PHI: Veteran Full Name, Name of Medication, Name of Physician. The medication was returned to the medical center. Update: 01/27/12:Veteran…

Outcome: Spoke with the mailroom and they will take more precautions in typing in addresses. Training will be provided to mailroom staff. Sent notification letter to affected Veteran.…

Issue: Patient A says that on Wednesday 01/18/12, he was in Audiology to schedule an appointment. The patient says he was talking to Employee A when her personal phone rang. The patient says the employee told him she had family issues…

Outcome: A recommendation has been made to the supervisor for appropriate administrative actions to be taken against the employee as well as refresher training.

Issue: Veteran B's completed 10-10EZ, DD214 and certificate of military service were put in an envelope with Veteran A's blank 10-10EZ. When Veteran A received this information, he immediately notified the VA Health Resource Center of this incident and faxed them…

Outcome: 1-20-12 - Credit Monitoring letter was sent to Veteran - the Supervisor of the enrollment office notified me that the employee responsible for the mismailing had been issued a written counseling - all staff in this office were reminded to…