VA Great Lakes Health Care System (VISN 12)

Issue: Veteran A was accidentally given Veteran B's eligibility paper work in the Emergency Department. Veteran A placed Veteran Bs information into his personal cell phone to file a compliant at a later time.. Veteran A alerted staff of the mix…

Outcome: All staff have been re-educated on proper procedures for handling PHI/PII and reminded to verify any paperwork before handing it to a patient.

Issue: A patient reported his medications had been tampered with when received by UPS. Medications were missing and the package was tampered with exposing patient information. This has been reported to police and Office of Inspector General (OIG). Update: 04/17/12:The patient…

Outcome: Being handled legally and internally.

Issue: A patient reported medications were tampered with when received by UPS. The medication package was open, medications was missing, and information was available. This has been reported to Police and Office of Inspector General (OIG). Update: 04/17/12: The Patient will…

Outcome: This is being handled internally through investigations involving police and IG.

Issue: Medical record documents of an active duty spouse were milsfiled in the record of another active duty member. the documents contained the spouse's name, full SSN, date of birth and protected health information (PHI). Update: 04/13/12:An active duty military member…

Outcome: Supervisors of the DoD and FHCC file rooms conducted refresher instruction to their respective file clerks. Credit monitoring letters were prepared and mailed.…

Issue: Patient A received medical records for another Patient who is a mental health patient. Records included lab results, a medication list with notations for mental health and pregnancy, along with Patients B's full name and full SSN. Update: 04/06/12:One Veteran…

Outcome: Employees cautioned to exercise accuracy.

Issue: The Schedule of Operations List, parking stickers, and parking sticker validation lists are missing. Information is routinely secured in a locked drawer at end of each shift. Only two individuals have keys to the drawer. Information was not in the…

Outcome: We have recovered the information. We have also re-emphasized to the staff the importance of protecting our patients information. All hard copy patient information has been removed from that area and is no longer stored there.…

Issue: A VA Administrative office was broken into at Rock Valley Community Program Grant Per Diem Program. The safe was broken into, the police were notified, and the premises searched. It is unknown if Veteran files were reviewed. The hard copy…

Outcome: Staff at the facility had secured the records and have transferred them to another secure area file cabinet following the break in. No reason at this time to assume the records were looked at or anything removed although the possibility…

Issue: Veteran A called the Pharmacy to state that he had not received his medications. The Pharmacy tracked through UPS and determined the medications had been shipped to the Veteran's old address. The person at old address was contacted but denied…

Outcome: Staff were education on accuracy of addresses.

Issue: During termination proceedings, an employee was sent notification twice to co-worker's address on file. The letter had the employee's correct address, but the outer envelope had the co-worker's address. The letter was sent via USPS and UPS. No letter was…

Outcome: We have re-emphasized to the staff the importance of protecting our employees information.

Issue: A VA doctor wrote a total of three (3) prescriptions (two (2) for Vetertan A and one (1) for Veteran B) and gave them to the MAS clerk. The two prescriptions for Veteran A were to be mailed, the one…

Outcome: Credit-monitoring letter sent, and the supervisor of the responsible employee has taken appropriate supervisory action.