South Central VA Health Care Network (VISN 16)

Issue: Veteran A stopped by the pharmacy and reported that on 03/08/11 he picked up his in-patient discharge medications. Later he discovered that he had received two prescriptions for Veteran B. Update: 03/24/11:Veteran B will be sent a notification letter.…

Outcome: Changing the pharmacy to include that the Pharmacy employee who dispenses the medication must first verify that the dispensing box is empty before placing more medication in box.

Issue: A nurse in the Emergency Room (ER) had Patient A sign the discharge instructions for Patient B. The nurse printed the instructions and gave a copy to Patient A, which contained full name and full SSN of Patient B. The…

Outcome: Supervisor of emergency department will be providing all the education.

Issue: Employee A accessed the record of Employee B who is Employee's A supervisor. Update: 03/16/11:Veteran/Employee B will receive a letter offering credit protection services.…

Outcome: Supervisor discussed incident with employee and could not validate if access was intentional or accidental. Privacy Officer preparing notification to service chief requiring employee to retake privacy awareness course; ISO's continue to conduct sensitive record access audits.…

Issue: It appears that a Consolidated Patient Account Center (CPAC) employee accidently put Veteran A's patient payment history report from 01/01/10 - 03/09/11 in with Veteran B's letter. Veteran B contacted the Health Eligibility Center (HEC) and sent the informaiton to…

Outcome: Appropriate actions taken against employee per discussions with supervision. Additional training for all staff reminding them of the importance of being careful whenever dealing with patient information.…

Issue: Veteran A received a copy of Veteran B's appointment list. Update: 03/16/11:Veteran B will receive a letter offering credit protection services.…

Outcome: The service that made the mistake was contacted and the staff have been briefed concerning the care necessary when dealing with mailing out appointment list to include including appointment list to patients upon departure\discharge from the VA. Supervisor provided training…

Issue: Employee A entered the record of Employee B. The employees are married. Update: 03/14/11: This is not the first time the spouse look at their spouse's record. It is unknown if the spouse (Employee B) knows that their spouse looke…

Outcome: Supervisor met with employee A and discussed incident. No valid reason why employee A accessed employee B's record. This is a second offense of inappropriate access by employee A into employee B's record. Privacy Officer preparing memorandum to Service Chief…

Issue: Medical Examiner's Certification of Mobility Impairment was mis-mailed to a VA employee of the same name as the Veteran patient (Veteran A) to whom the document belongs. The document has been recovered by the Privacy (PO). This incident involves only…

Outcome: Clinic Manager reinforced policy and procedures for mailing of PHI.

Issue: Veteran A received his appointment letter along with appointment letters for three other Veterans (B, C, and D). Update: 03/10/11:Three (3) Veterans will receive a notification letter.…

Outcome: Education and Privacy Awareness training provided.

Issue: Patient found sheets of paper with patient info in his room. Information included the last name, last 4, room number, diagnosis, and treatment plan for 17 patients. Update: 02/28/11:All 17 patients will be sent letters of notification.…

Outcome: Unable to determine who actually left information in the room - all staff was reminded to take time when working with patient information and provide adequate safeguards for the information.

Issue: Veteran had a sleep study - employee saw her - texted her next day - she replied "wrong number". Veteran's friend called the number and the person identified their self as "Jason" and advised he got her number off the…

Outcome: Service decided to do a written counseling for the involved employee. PO will receive copy of the letter for files.…