VA Healthcare - VISN 4 (VISN 4)

Issue: Veteran A received Veteran B's medical records. Veteran A returned Veteran B's medical records to medical center eligibility staff. Update: 06/11/12:Veteran B is deceased, so their next-of-kin will be sent a notification letter. Veteran B's name, SSN, and medical information…

Outcome: Veteran B's records were returned to the medical center by Veteran A.Veteran A's paper and electronic charts were reviewed and did not contain Veteran B's records.Veteran's B paper charts were received from the Federal Record Center and it was verified…

Issue: While the engineering staff was in the women's locker room moving lockers, medical documentation was found in one of the lockers. This information was dated for the year 2002. It looked like it had been in the locker since 2002.…

Outcome: Notification letters signed by the Director and will be mailed on 7-18-12Nursing Office was notified about this issue and instructed on education to staff on correct storage and disposal of PHI and PII

Issue: Veteran A was given Veteran B's medication on 05/23/12. Veteran A left the facility and returned home to his residence. Later the same day, Veteran A contacted the medical center pharmacy, returned the medication, and received the correct medication. There…

Outcome: Pharmacy Staff reminded on the importance of accuracy when dispensing medications

Issue: Veteran A was given Veteran B's medication. Veteran A left the medical center's pharmacy counseling area and was contacted by the pharmacist by cell phone prior to leaving the medical center. The medication was returned by Veteran A to the…

Outcome: Pharmacy staff were reminded on the importance of dispensing accurate medications to patients.

Issue: Veteran contacted the medical center on 06/05/12 to state that he was contacted by Brand Comfort sales department on 06/04/12. Veteran stated that the sales person told him that he is currently on Viagra and that their company could provide…

Outcome: Information was forwarded to the Greater Lakes CMOP for followup on this issue.

Issue: Veteran A called and reported that they had also received Veteran B's medication paperwork in an envelope that they received with their prescription.Veteran B was contacted by pharmacy staff and they did not report that they had received any other…

Outcome: Advised pharmacy supervisor to reinforce good quality control methods.

Issue: The Privacy Officer (PO) will need to gather more information, but the daughter of Veteran A mailed in an application to our VA and somehow that application was incorrectly mailed out form the VA to Veteran B's home. It seems…

Outcome: The Supervisor of the department is making the employees retake Privacy/HIPAA training course 10203. Procedures are also being reviewed and those needing changed will be changed…

Issue: The VA Police reported an incident regarding a suspicious vehicle on VA property at 9:45 PM. The VA Police discovered a VA employee who was attempting to move boxes of documents that contained personally identifiable information (PII) and/or protected health…

Outcome: This VA employee was in clear violation of VA Privacy Policies. A violation memo is being prepared and will be routed to the service line VP, and HR employee/labor relations for further administrative action.

Issue: Appointment List printed on March 14, 2012 by VA staff. It was found by VA staff at the end of April in our Domiciliary dayroom. Various patients, visitors, staff, could have had access to the information. We do not know…

Outcome: PROCEDURES WERE CHANGED. A PATIENT LISTING WILL NO LONGER BE PRINTED. CHAPLAIN STAFF WILL NOW GO INTO CPRS TO LOCATE THE NEEDED INFORMATION WITHOUT THE USE OF THE LIST. REMINDED STAFF OF THE IMPORTANCE OF GUARDING INFORMATION. AND WILL BE…

Issue: Veteran A had requested and was provided medical records from the release of information office. Veteran A however sent back several pages of the documents that were released which contained correct name, SSN and date of birth, but the notes…

Outcome: The records have been corrected and notification has been completed. This error will be addressed to the COS office to advise that proper medical documentation is very important.