Sierra Pacific Network (VISN 21)

Issue: A VA patient left the Dermatology Clinic with his medication profile. The patient also picked up the printed appointment list that was on the doctor's desk. The doctor realized the appointment list was missing, The nurse called the patient who…

Outcome: Appointment lists are kept in a plastic sleeve to prevent veterans from accidentally picking it up.

Issue: A registered nurse (RN) called in on Wednesday 07/06/11 requesting emergency annual leave. She had received a phone call from a family member and learned that her uncle was missing. She called another RN several times that day asking if…

Outcome: Appropriate administrative action(disciplinary) has been taken.

Issue: Patient B received the medications for Patient A; Patient A's name is the same as Patient B. The medication labels have the date of birth but it is scrambled. The only information disclosed to Patient B regarding Patient A was…

Outcome: Business Office staff responsible for updating address will be inserviced by Supervisor regarding verifying address before entering changes.Redacted letter has been downloaded to PVTS; please close this ticket.

Issue: Patient was referred to outside provider since care could not be provided at Community Based Outpatient Clinic (CBOC). Referral provider's office mistakenly disclosed patient name to drug/supply representative for possible future treatment. Drug representative then starts soliciting CBOC to start…

Outcome: Contacted individual at referral provider's office and informed her that patient name shouldn't have been disclosed to pharmacy/supply rep especially since course of treatment wasn't discussed with or approved by referring provider. Pharmacy/supply rep was going to be called by…

Issue: The Lab results of Veteran A were mailed to Veteran B; Veteran B notified the regional VBA Privacy Officer who notified this Facility Privacy Officer. The information disclosed was the full name, address and full SSN of the Veteran A.…

Outcome: Credit Monitoring letter mailed 6-28-11, Supervisor provided training to in-service staff regarding quality control when releasing PHI.…

Issue: An employee found two pages of a pharmacy report regarding medication errors that were discontinued. The report included the patients last name, complete SSN, and medication information. Update: 06/15/11:Two Patients information was found therefore two (2) Patient will receive a…

Outcome: Provided reeducation to all staff on the importance of safeguarding patient information and how to properly dispose of it.

Issue: A Security/Privacy incident was discovered on 06/08/11 at approximately 3:20 PM. The incident was reported to Information Security Officer (ISO) by a VA employee located at the VA NCHCS, Fairfield OPC. The incident occurred when a small trashcan containing several…

Outcome: Contract housekeeping staff were educated on the what containers are trash and which ones are shred it containers by the supervisor of the contract.

Issue: Medications for Patient A were mailed to Patient B. The wife of Patient B called to inform facility that they had received medications for another Veteran, she stated that they would return the medications. The information disclosed was the name,…

Outcome: Pharmacy Supervisor to in-service staff to be more diligent in checking medications before shipping to prevent unauthorized disclosures.

Issue: A Claims file was sent to this facility and a Veteran underwent three exams. The last exam occurred on 05/11/11. According to the clerk, the file was placed in a rack outside of the Fellow's door. According to the Attending…

Outcome: On 6/29/11, PO met with the lead receptionist for the clinic to review their procedures for securing C&P files. She explained after the patient checks in for their appointment, their file is placed in the 'conference room' for review by…

Issue: Patient A received clinic appointment notices for Patient B and Patient C along with his own clinic appointment notice. Patient B's full name, address and partial SSN was disclosed, Patient C's full name, address and full SSN was disclosed. Patient…

Outcome: Supervisor of department that is responsible for mailing clinic appointment notices has in serviced staff regarding the need to be thorough and double check notices before mailing.