South Central VA Health Care Network (VISN 16)

Issue: An individual placed the wrong arm band on a patient. It was found before the individual had their procedure Update: 05/01/13:One Patient will be sent a letter offering credit protection services due to full name and full SSN being disclosed.05/22/13:This…

Outcome: PO has actually placed signage regarding individuals getting too close when there is someone else in the area. this was to have contributed to the incident.Signs and tape... as well as education for the staff have occurred.c.m. letter sent outsee…

Issue: A Veteran's laboratory results for the timeframe of 1-19-13 to 2-19-13, printed on three pages, were mailed to the wrong address. The recipient of the letter opened the letter, taped closed, and returned to sender (VAMC). The VAMC mailed the…

Outcome: NA

Issue: A research study coordinator in the process of retrieving the medications for one of the research participants discovered a medication bottle for another patient was missing. After searching it was discovered that two medication bottles for two different research participants…

Outcome: Copy of ticket provided to Research Compliance Officer for ORO notification and referral to IRB for appropriate action. Notification sent to Veteran.…

Issue: The Research Compliance Officer reported that while in the process of scheduling an audit of a closed research study the principle investigator reported he was unable to locate the consent forms for the two individuals enrolled in the study. He…

Outcome: Research Compliance Officer notified Office of Research Oversight and local Institutional Review Board for appropriate action and follow up.

Issue: Veteran A has the same first name, same last name and same middle initial of Veteran B. Veteran A was mistakenly admitted under Veteran B's identity. Veteran A had Veteran B's information on his armband which included Veteran B's full…

Outcome: This patient was transferred to OKC VAMC under the incorrect name and social security number from another facility.

Issue: An unidentified patient called into the clinic and stated that he received two other Veterans' appointment letters along with his. He identified the two other Veterans. PM&R clinic noted that the two Veterans had same appointment dates for Occupational Therapy.…

Outcome: Appointment letters are completed by a machine in the mailroom. The mailroom has been notified and will be monitoring more closely to ensure that the machine is working properly.…

Issue: The arm band with the name of a deceased patient was placed on another patient. It is not known which employee is responsible. Staff are working to get statements and system will be updated Update: 04/23/13:The Veteran's Next of Kin…

Outcome: The armband was not saved after the misidentification happened.. so the CBO could not see specifics of the armband.The problem is that the individual died in 1993 and their spouse died in 2000... there is no one else listed to…

Issue: Seven VA Employees inappropriately accessed Seven other Veteran/Employees electronic Health Records (eHR). Update: 04/23/13:The seven (7) Veteran/Employees will be sent notification letters.05/29/13:This was determined to be HITECH reportable by VHA Privacy Office.…

Outcome: Accesses revoked in accordance with new Minimum Necessary Standards; personnel action taken.

Issue: The Privacy Officer received a call from VISN Information Security Officer stating a student nurse accessed her dad's (Veteran's) account and advised him not to take certain medicine that have been prescribed by his provider. Access has been blocked at…

Outcome: Student was terminated from clinical practice.

Issue: An RN discussed a Veteran's protected health information with his spouse. The RN did not have authorization, power attorney or legal documents to do so. Update: 04/23/13:The addendum note by the nurse states she was told by Veteran's spouse the…

Outcome: The employee took privacy training again. The PO provided training to primary care nursing staff on 04.24.2013.…