VA Health Care Upstate New York (VISN 2)

Issue: The Outpatient Pharmacy Supervisor reported that there was a delivery error where Patient A received Patient B's prescription with his order. Patient B's prescription was sent in error with two correct prescriptions for Patient A. These were Scriptalk orders which…

Outcome: Outpatient Pharmacy Supervisor confirmed receipt of medication back from Patient A that he received in error. Pharmacist and pharmacy students involved in the wrapping process re-educated on the requirement to confirm 2 patient identifiers before wrapping the medications for mailing.

Issue: The Social Work Executive notified the Privacy Officer that a Nurse Practitioner at the Binghamton Outpatient Clinic in an attempt to contact the appropriate community agency (child protective services), ended up contacting the incorrect department (adult protective services). Both of…

Outcome: Nurse Practitioner, social worker, and all other clinic staff educated at the last clinic staff meeting regarding the policy for proper reporting to Adult and Child Protective Services.

Issue: The Privacy Officer (PO) completed the Quarter 3, FY 12 Release of Information audit and identified personally identifiable information (PII) and protected health information (PHI) and 7332-protected information was released to outside third parties without proper authorization for 11 Veterans,…

Outcome: Results submitted to the HIMS Manager who reviewed and submitted a request ro HR for progressive disciplinary action due to previous violations and pending disciplinary action on file with the employees. Received confirmation that disciplinary action in the form of…

Issue: An Environmental Management Service (EMS) staff member threw out a box of prosthetic forms (VA form 10-1394 & VA form 10-0103) that had been set aside for an office move. At first it was thought that it was misplaced in…

Outcome: PO provided educational sessions for EMS and Prosthetics departments on safeguarding, disposal and proper notification if an event happens.

Issue: The Health Information Management Service (HIMS) Supervisor found a plastic bag outside of the Pharmacy with Veteran A's last name first initial, last 4 digits of the SSN, room number, and medication laying on floor. Update: 07/26/12:Veteran A will receive…

Outcome: Reminded staff to be careful of labels.

Issue: The Emergency Room (ER) completed COBRA transfer form with wrong patient information. Transferring veteran and employee who was treated in ER earlier both have same last name. Form has full name, SSN and address for employee not Veteran. PHI on…

Outcome: referred to Patient Safety on misidentificaiton. Other hospital notified of incorrect demographics.

Issue: Veteran A asked for an echocardiogram to be released to him to take to his external physician. When he was at his providers office it was discovered by the physician that Veteran B's had been uploaded into his record. This…

Outcome: Credit monitoring letter mailed to Veteran 7-16-12

Issue: The Outpatient Pharmacy Supervisor reported to the Privacy Officer (PO) that two patients' medications were switched at delivery by the Pharmacy technician. Patient A received Patient Bs medications but Patient As medications was never opened by Patient B because the…

Outcome: Patient A and Patient B's medications returned to the hospital and resent correctly. The technician was counseled by the supervisor and is aware of his error. He was told to be sure to only work on wrapping these orders one…

Issue: The Emergency Department Service Chief reported to the Privacy Officer (PO) that Patient A received the discharge instructions with Patient B's patient identification label on it, resulting in Patient B's name, full SSN, and DOB being inappropriately disclosed to Patient…

Outcome: ED Service Chief confirmed that Patient B destroyed (shredded) his discharge instructions that contained Patient A's identification label. The ED physician was counsled on his error and educated to confirm patient identifiers before handing the discharge instructions to the patient.

Issue: The Release of Information (ROI) department received a request from an insurance company for information regarding SS benefits for Veteran A. They asked for a letter to be sent to them however the clerk released all records from 2008 to…

Outcome: The Release of Information Department supervisor went over the need to only release the minimum necessary when processing a request with the clerk. Credit monitoring letter mailed to Veteran 6-26-12