VA Health Care Upstate New York (VISN 2)

Issue: A Veteran received call from her estranged father on her cell phone. Her number had been changed and it had not been given to him. He stated to her he was going to attack her at home after her surgery.…

Outcome: NA

Issue: Veteran A was given his lab results during his appointment to give the lab results to outside provider. The outside provider noted that they were actually lab results for Veteran B. Outside provider shredded the results. Update: 04/26/13:Veteran B will…

Outcome: Staff reminded to confirm the correct Veteran's name on documentation before providing them to the Veteran.

Issue: 2 Western New York employees accessed the sensitive Electronic Medical Record (EMR) of a non-Veteran employee without authorized access. Update: 04/22/13:Non-Veteran A will be sent a notification letter.05/22/13:This was determined to be non-HITECH reportable by VHA Privacy Office.…

Outcome: Staff in area of incident have been reeducated.

Issue: A surgery patient list was left on a table in a conference room. The list contained 26 Veterans' names, last 4 digits of the SSN, room number, age, attending physician, diagnosis, procedure, medications, diet, and diagnosis (including three with 7332…

Outcome: Issue was reviewed at staff meeting.

Issue: VA Veteran/Employee reports that medical records which were initially mailed and returned from non-VA provider were received in 2 packages which were torn and partially opened. Update: 04/16/13:The Veteran/Employee will be sent a letter offering credit protection services due to…

Outcome: NA

Issue: While reviewing an eOPF file, Human Resource Employee noted a personnel action scanned into the wrong employees file. Item is from 2008 so most likely has been in the wrong file for since 2009 when paper files were scanned by…

Outcome: Images removed from wrong employee. items so old unable to determine who scanned them.

Issue: Deceased Veteran's step-daughter called and spoke with Social Worker. She questioned whether Veteran had a diagnosis of PTSD. Social Worker checked the patient's record, did not find a diagnosis, but disclosed that the Veteran did have PTSD symptoms. Update: 04/17/13:The…

Outcome: Education/reprimand provided to Social Worker.

Issue: The Outpatient Pharmacy Supervisor reported that there was a delivery error of a patient's prescription. Patient A's prescription was mailed to Patient B. The prescription was returned by the Patient B when it was discovered. This resulted in Patient A's…

Outcome: Pharmacy resent the medications to Patient B and had the software technician make system changes to correct the error occurring with the printing the labels to avoid future occurrences.

Issue: Veteran A was discharged from a Post Traumatic Stress Disorder (PTSD) program and given his medications in a plastic bag. Today when the Home Health Nurse went to visit, she noted the bag also contained medication for Veteran B. The…

Outcome: The items were retrieved and returned to the pharmacy.

Issue: Resident Physician in the Eye Clinic reported that he had taken home patient information last night after performing a surgical case in the OR which he placed in his back pack and left locked in his vehicle. The Resident identified…

Outcome: The Chief of Ophthalmology has reviewed with all of the residents the importance of protecting patient information. In addition, he asked each to sign a memo stating the following: 1) that the residents have reviewed with the Chief, the importance…