VA Health Care Upstate New York (VISN 2)

Issue: Patient A and Patient B received each other's medications in erroor. The patients medications were switched while being wrapped for delivery. Both Patients take the same medication but received each others bottles but no paperwork from the other patient. This…

Outcome: Employees responsible for the error were educated by their Supervisor regarding the requirement to confirm 2 forms of patient identity before wrapping for mailing.

Issue: Privacy Officer notified by VA Police that Veteran sensitive information was found in a trash bin after being placed there by housekeeping when cleaning out vacated offices on the 7th floor after a move. Upon further review it was determined…

Outcome: Administrative Officers educated on the requirement to properly box, label, and secure records in preparation for an office move. In addition, a Standard Operating Procedure was developed for this and provided to the Space Committee, who will provide this to…

Issue: A visitor found a list of patients medicine on elevator and took it to information Security Officer who secured it. The list contains 16 veterans last name, one with first name, last four ssn, diagnosis, medications, tests, labs, and Next…

Outcome: PO met with COS, Chief of medicince, Educatio Officer and Chief resident, updated template so last 4 SSN removed. Provdided training to residents.

Issue: Medical resident was walking in parking lot across street at university and found the ICU sign out sheet for the providers laying on the ground. Immediately picked up and secured. Gave list to Chief Resident who reported the issue. Update:…

Outcome: Changed sign out sheet to remove last 4 SSN. In process of converting to electronic instead of paper.

Issue: A VA employee found a printed End of Shift report in the parking lot containing medical information, full names and social security numbers on 20 Veterans. The employee picked up the information and gave it to a nurse manager who…

Outcome: Document in parking lot was recovered. Education was provided to all staff on nursing unit where papers originated on patient privacy and proper handling of patient information. Additional reminder/information given regarding who can/should be notified for potential privacy issues.…

Issue: Medication instructions received by Veteran A were mailed to Veteran B for the same medication prescribed. Update: 09/11/12:Veteran A will be sent a notification letter.…

Outcome: Privacy Officer assessed the incident and provided information regarding proper handling of medication instructions to VA employee.

Issue: A Medical Intensive Care Unit (MICU) resident left handoff sheet for 7 Veterans on counter by coffee stand in Lobby. Chief Engineer found and brought to Privacy officer. Sheet has 7 veterans, last name, last 4 SSN, admission date along…

Outcome: PO met with COS, Chief of medicine and Chief Resident to discuss info on sign out sheets. Reviewed to eliminate unnecessary identifiers.

Issue: A VA RN sent the wrong letter to Veteran A. the letter discussed results of cat scan and follow up. She had the wrong Veteran's name and address. She contacted Veteran who received wrong letter and asked him to destroy…

Outcome: Staff educated on having multiple session of CPRS open leading to issue. Also reviewed checking name on letter before sending.

Issue: Veteran mailed package certified to Director. FU by veteran found the package was not delivered to Director. Confirmed package was received by VA employee. Unable to locate. Contained complaint from several veterans, full name and last 4 SSN, and then…

Outcome: Please advise, unable to locate package internally. Reviewing procedure on packages delivered to Directors office.…

Issue: The Records Center sent one perpetual medical record to VA via UPS. When the mailroom received the envelope, both the envelope and contents were water damaged. The seams to the package had been unsealed due to the water exposing the…

Outcome: Record sent for remediation of water damage. Logistics has reported issue to UPS.