VA Healthcare - VISN 4 (VISN 4)

Issue: Veteran A & Veteran B each made individual requests for release of information. When responding to B the clerk in error mailed to B the records of both B and A. B lives near A and delivered A's records to…

Outcome: Employee counseled within chain of command, which recommended appropriate action through Human Resources.

Issue: Veteran A and Veteran B were sent eachothers lab results by mistake. They included the other Veterans full SSN. Update: 09/12/11:Both Veterasn will be sent offers for credit protection services.…

Outcome: Supervisor has reeducated employees about better Quality Assurance measures.

Issue: During a training class, a sign-in roster was distributed with names and social security numbers. Update: 09/07/11:According to the Information Security Officer (ISO), the Environmental Management Service (EMS) Section Chief printed the roster as a sign-in sheet for a class…

Outcome: The staff member was counseled for inappropriate use of SSN.

Issue: There was a packing error in the Pharmacy. In the UPS database, the name of each Veteran was listed and the wrong one was selected when printing the postage. Veteran B's information disclosed consisted of: full name, full address, and…

Outcome: Training was conducted for the pharmacy staff member on the importance of proper packing procedures. This topic will be brought up again to staff members during their staff meetings.…

Issue: Patient A realized that the patient wristband placed on his wrist was not his. The wristband on his wrist pertained to Patient B. The wristband contained Patient B's name and full SSN.Patient A identified the mistake within 30 minutes and…

Outcome: The employee was reeducated by the clinic supervisor regarding this type of error and to ensure proper identification of patients when putting on patient wristbands. The clinic manager will conduct a post incident training brief at the next staff meeting…

Issue: Two prescriptions were filled and got mixed-up and were sent to the incorrect Veterans. Update: 08/09/11:Veteran A and B will be sent a notification letter.…

Outcome: The staff in the area were re-educated on checking packages before mailing.

Issue: A VA employee reported that another VA employee admitted to accessing her former husband's medical record. Update: o7/29/11:The former husband will receive a letter of offering credit protection services.…

Outcome: Service Line Mgt and Human Resources are determining disciplinary action for this employee.

Issue: A Veteran called into report that a letter was received in the mail from the VA and in the letter was the information of another Veteran. Update: 07/18/11:One Veteran will receive a letter offering credit protection services due to full…

Outcome: Service line management has indicated they will coordinate training with the PO and review the process that led to this error. Employee training sign-in sheets were received.…

Issue: Veteran A received his lab work report in the mail. Included in the envelope was Veteran B's lab work report. Update: 07/14/11:Veteran B will receive a letter offering credit protection services.…

Outcome: PO recommends the work area be secured with limited access to those employees/volunteers performing the function of mailing documents. In addition, PO is requesting re-education with employees/volunteers by the clinic Supervisor and to provide the sign-in roster to the PO…

Issue: A Veteran called and reported to the CBOC that a letter was received but the inside contents of the letter pertained to another person. The Veteran was advised to bring the mismailed document to the CBOC or send the envelope…

Outcome: Re-educating all staff to verify proper documents are placed in proper envelopes.