VA Healthcare - VISN 4 (VISN 4)

Issue: Veteran A had a prescrption filled on 11/01/11 for a Class II narcotic medication. It was given by mistake to Veteran B whose husband signed for the medication. Both Veteran A and Veteran B had the same medication filled within…

Outcome: Pharmacy staff was re-trained by the Supervisor of Pharmacy on the importance of ensuring accuracy when dispensing medication

Issue: Veteran A called the Information Security Officer and reported that he had received a copy of Veteran B's EKG in the mail. Update: 11/08/11:Veteran B will be sent a letter offering credit protection services due to full name and full…

Outcome: After investigation by the PO, it appears the two Veterans had outpatient appointments on the same day in May. It is assumed that the one Veteran's information was given to the other Veteran on the day of appointment, which was…

Issue: During a routine visit to the Radiology Department a patient was issued an incorrect patient ID wristband at the check in desk. The patient realized later that they had the incorrect wristband just prior to a test being completed, the…

Outcome: Department supervisor is conducting training and re-educating staff about better quality control measures.Management is considering administrative action for 1 employee that has had more than 1 error in a short period of time regarding this type of incident.

Issue: On 11/02/11, the Alternate Privacy Officer (PO) received a call from Patient A who reported that he received via mail his prescription and the paperwork included in the mailing was for Patient B. Patient A indicated that the prescription itself…

Outcome: The Chief of Pharmacy will address both the staff that processed this prescription one on one and will also provide education to the entire staff. Resolution Date: Nov. 3, 2011 The Chief of Pharmacy has made a revision to the…

Issue: Veteran A called into the Community Based Outpatient Clinic (CBOC) and reported that he had been given an appointment list, however the list provided pertained to Veteran B. Update: 11/03/11:Due to full SSN being disclossed, Veteran B will be sent…

Outcome: The document has been recovered. The CBOC Clinic manager and the Primary care CBOC manager are looking at a way to assess the issue that occurred, and are working on corrective actions.…

Issue: Veteran A received his lab work results in the mail and included were Veteran B's lab work results. Update: 10/31/11:Veteran B will be sent a letter offering credit protection services, as his full SSN and lab work results were disclosed.…

Outcome: Service line management, the COS, and director have been advised of this incident and also advised that this has been identified as a recurrent issue within 1 specific area. Quality and Patient Safety have been contacted and are in the…

Issue: Veteran A received two radiology appointment letters in the mail. One letter was correctly addressed to him and the other letter was for Veteran B. The letter contained Veteran B's full name, last four digits of the social security number,…

Outcome: The supervisor of the area reminded staff to make sure the correct information is put in the correct envelopes.

Issue: EMPLOYEE VETERAN IS AN INPATIENT ON OUR MEDICAL FLOOR. A FORMER NURSE WAS ON THE WARD VISITING HER HUSBAND WHO IS ALSO A PATIENT. SHE LOOKED AND SAW THE EMPLOYEE VETERANS NAME ON THE DOOR AND ASKED A NURSE WHY…

Outcome: Employee was given a reprimand for this action and was placed in her OPF. She understands the error she made. The PO will also send out an announcement to the entire VA Medical Center as a reminder of the importance…

Issue: The pharmacy received a call from Veteran A stating that he received his medication lotion labeled for Veteran B. All other paperwork was correct but the prescription label was incorrect. Both patients had orders for the medication lotion but the…

Outcome: Pharmacy staff was re-trained on the importance of ensuring accuracy when dispensing medication with the robotic computer machinery.

Issue: A Veteran alleges that a VA Intern accessed his medical information and disclosed it to another individual. Update: 10/31/11:The Veteran will be sent a notification letter due to protected health information (PHI) being accessed inappropriately.…

Outcome: The Director of the VA Intern's Education Institution was briefed about this situation. The VA Intern was told to immediately report back to the Institution and was given a 21 day suspension and further action will be dependent on the…