South Central VA Health Care Network (VISN 16)

Issue: It seems that Veteran A had a procedure at the Central Arkansas Veterans Health Care System (CAVHCS) on 09/20/12. He later realized that he had received Veteran B's information. He contacted the patient representative at his facility and they reported…

Outcome: Staff have been dealt with appropriately regarding the appropriateness of assuring the correct individual receives the correct information. Please see attached letter.…

Issue: Veteran A was at Central Arkansas VA Healthcare System (CAVHS) on 09/13/12 for a procedure. Veteran B was also having a procedure on the same date. Veteran B's medication sheet was given to Veteran A which included Veteran B's full…

Outcome: Re training regarding the importance of making sure you are working with the correct patient in the correct medical record. Appropriate action taken.See attached c.m. letter than went out 10 02 12…

Issue: An employee found a copy of a Progress note in the restroom. The note included a Veteran's full name, SSN, and a request for transportation. Update: 09/12/12:The Veteran will be sent a letter offering credit protection services, due to full…

Outcome: PO and ISO continue to send out message to All Employees regarding patient privacy.

Issue: A VA employee was faxing some additional purchase order documents to a vendor and accidently sent a copy of the information to the vendor. Update: 09/05/12:The information is a list of open consults which contained the type of consult, tname…

Outcome: Employee has been canceled regarding privacy issue.

Issue: Veteran A contacted the pharmacy today to report that Veteran B had mailed him a letter along with prescription paperwork that belonged to Veteran A. He contacted the pharmacy to be sure that all of his medications were correct in…

Outcome: Employees provided continued education for privacy awareness.

Issue: A Veteran called to inform the Privacy Officer (PO) that he had received a copy of another Veteran's medication list in the mail with the confirmation letter of his appointment. He will mail the list back to the PO. Update:…

Outcome: Note has been retrieved. Staff re-educated regarding patient privacy and confidentiality.…

Issue: The Social Work Clerk misunderstood who the denial letter was supposed to be sent to and sent it to the Veterans parents address instead of the Veterans address. The parents are listed as next of kin but aren't on the…

Outcome: Talked with SW Supervisor about training the Social Workers about PHI.

Issue: Initially, the Privacy Officer reported that Veteran A contacted the facility but that was in error. The facility observed the wrong Veteran B's name, ssn and dob were placed in the wrong record. The correct information was provided to the…

Outcome: Appropriate actions to be taken with staff. Currently looking at additional changes in SOP to assure that more time is taken in verification of individuals.…

Issue: VA Employee found a copy of the Inpatient Roster listing the full name, last 4,digits of the SSN age, date of admission, ward, and room-bed number for 4 patients. The list was found on the ground on the 3rd floor…

Outcome: Supervisor has been notified and appropriate action taken. Copies of letters scanned.

Issue: Email was erroneously sent to vhaalxall (all employees at facility) that included the full name, full address and full telephone number of a potential volunteer. Update: 08/20/12:Due to the email being sent to the whole facility email lists Individual A…

Outcome: Refresher training provided by PO to individual who sent email. Also, redacted credit monitoring letter uploaded.…