South Central VA Health Care Network (VISN 16)

Issue: PO while round in an area of the NLR Campus noticed a piece of paper folded. Upon review of the paper - it was an inpatient roster of 21 names. It has name, last 4, age, admission date, days in…

Outcome: PO was unable to determine who actually "lost" the information but training has occurred in the area. Letters went out 4/26/11.…

Issue: A copy of a morning report was found by an employee in the Medical Center's Canteen Cafeteria. A nurse left the report in the Canteen. It was there less than 30 minutes. The list contained the full name, SSN, diagnosis,…

Outcome: The nurse was counseled to be more careful with printed documents. The Privacy Officer (PO) and Information Security Officer (ISO) will remind all staff to print documents only when necessary and to shred documents containing personally identifiable information (PII) or…

Issue: Veteran A noticed once he left the facility that he had received someone else's information (full name, full SSN, DOB, and medication information. VA staff contacted Veteran B and he did not get any of Veteran A's information. Veteran A…

Outcome: P&P has been changes to require additional steps that should prevent such incidents occurring again.Actually if staff had followed the old procedure - it would not have happened.

Issue: Veteran A brought Veteran B's medication information to the Primary Care Clinic check in desk. It contained Veteran B's full name, last 4 digits of the SSN, address and telephone number. Veteran A received the medication information in with his…

Outcome: Unable to determine which staff member was ultimately responsible for the error as several were assigned to packaging that day they did provide notice to all staff in the NLR Amb Care Section (where error occurred) of the error and…

Issue: During an office visit, an incorrect note was entered on Patient A and the information was given to Patient B. The full name and SSN of Patient A was given to Patient B. Update: 04/04/11:Patient B will receive a letter…

Outcome: This was an inadvertent disclosure made by the provider who reported the incident to the PO. The provider contacted both the individual whose information was disclosed and the individual who has the incorrect information. Would like to offer the affected…

Issue: Upon admission to the appropriate ward, the Veteran shared with staff that he had 2 wristbands. One was his and the other was not. The last name and last four were the same. Update: 03/30/11:Veteran B will be sent a…

Outcome: Emergency meeting regarding issues with the armbands- Safety, CBO, PO, Nursing in the meeting - process changed and info sent out from the Director. Training has occurred again and important of checking patients for armbands.. correct placement of informationIt was…

Issue: Research compliance officer reported that a principle research investigator reported that the last page of a research consent form was discovered missing. It is unknown as to whether or not the form had the patient's full or partial social security…

Outcome: Research compliance officer reinforced with PI the requirement to maintain original consent forms as part of research data.

Issue: Veteran A received information from Social Work regarding the Health Care Advance Directives on file. The last page was not his own information. It belonged to Veteran B. Veteran A is concerned that Veteran B may have received his information.…

Outcome: Appropriate action taken. Staff are aware of the importance of maintaining privacy.. it was human error. and they admit this.…

Issue: The Privacy Officer recieved an email from Primary Care Clerk that advised he spoke to Veteran A's wife that he recieved a copy of Veteran B's primary care note. Update: 03/28/11:Veteran B will receive a letter offering credit protection services.…

Outcome: Spoke with Primary Care Clark about paying more attention to detail when mailing out PII to Veterans to make only information mailed is to Veteran all theirs. Notification letter mailed.

Issue: Veteran A was mailed a medication reconciliation list belonging to Veteran B, which also included Veteran B's full SSN. Update: 03/28/11:Veteran B will receive a letter offering credit protection services.…

Outcome: The PO instructed the PSA and their supervisor the importance of making sure that all mail that is being sent out is going to the correct veteran and that all documentation is for the same veteran.