Rocky Mountain Network (VISN 19)

Issue: Pharmacy mailed Patient A's refill information to Patient B. Patient A's information that was disclosed included his name, address and medication information. Update: 01/13/12:Patient A will receive a letter of notification.…

Outcome: It is unclear as to who mailed the one patient's prescription refill information to the other Veteran. The Chief of the service has been notified of this incident.

Issue: The wrong medications out to the wrong person. Veteran A and Veteran B had the same first name and were asking for the same medication. Veteran A was given Veteran B's diabetes medication. Then Veteran B came back a hour…

Outcome: The pharmacy tech has been counseled and will be watching the privacy training video for re-training purposes. Human resources is preparing documents for possible disciplinary action

Issue: Veteran A received the medication list intended for Veteran B from the provider. The provider handed Veteran A the medication list after she wrote some notes on it while she was seeing him. Veteran B had been seen earlier in…

Outcome: The admissions area supervisor has reviewed procedures with the staff member and she has been advised to retake the privacy and HIPAA training and inform the Privacy Officer of its completion.

Issue: VA employee left a copy of a medical record sheet in the travel bag of the vehicle that had been checked out. Fleet manager discovered document while doing fuel reciept audit. Update: 01/11/12:Veteran A will be sent a letter offering…

Outcome: Responsible individual counseled and retrained on Privacy Act requirements, Privacy Training recommenced.

Issue: A VA employee from Home Based Primary Care left a box of information outside of Building 4 which contained documents including patients' names, full SSN, visit dates, diagnosis, addresses, phone numbers and patient inquiry information. The estimated number of Veterans…

Outcome: On 01/06/12, the Privacy Officer (PO) interviewed the employee and updated the total number of Veterans affected. The box was examined by the PO and the employee stated the box was not tampered with. The PO completed the investigation on…

Issue: An employee accessed another employee/Veteran's medical record. Update: 12/27/11:The Employee/Veteran will be sent a letter offering credit protection services due to full name, full SSN and PHI being accessed without authorization.…

Outcome: PO has recommended appropriate action be taken against employee. Credit monitoring letter has been sent out 1/19/12.

Issue: The medications for Veterans A and B were placed in a UPS package and mailed to Veteran A. The information at risk includes Veteran B's name, address, date of birth and medication information. Update: 12/19/11:Veteran B will receive a letter…

Outcome: Materials retrieved and proper destruction according to Pharmacy regulations occurred. Department as a whole trained and new QA procedure put in place regarding second checking UPS packaging prior to securing.…

Issue: Date: 12/9/11 Issue: In CPRS, when staff want to add an additional signer to a Progress note, they must use their mouse to \xe2\x80\x9cRight click\xe2\x80\x9d on the note. This brings up a box with the names of all VA Montana…

Outcome: Education sent out to all VA staff that have access to the electronic medical record to use more caution when selecting a name as an addtional signer. Also PO is keeping track of alerts reported for follow up.…

Issue: A VA employee took the daily blood draws from the Lakewood Community Based Outpatient Clinic (CBOC) and left them in his car overnight and returned them the next day. The test tube labels contain patients' full name, partial SSN and…

Outcome: Employee on Administrative Leave since 12/14/11. Supervisor working with HR. Requested update on incident from supervisor. Waiting on HR response to proceed with action against employee. Letter sent 1/17/12 to all Veterans.…

Issue: The wife of Veteran A was given the discharge papers to sign for Veteran B. She took them with her, but stayed at the VA facility. When she was informed the Veteran was still in the surgery department, she returned,…

Outcome: Education to Surgical staff- supervisor to give re-training in regards to a reminder to insure they verify the ID of the paperwork to the patient getting discharged.