VA Healthcare - VISN 4 (VISN 4)

Issue: Both Patient A and Patient B had pending prescriptions for the same medication. Medication for Patient A was filled under Patient B's name. The incorrect name was selected in the ScriptPro dispensing system. Update: 04/05/11:Patient A will be sent a…

Outcome: Pharmacy staff were re-educated on the importance of dispensing correct medication to patients.

Issue: Patient A reported that she received her medication via mail and along with it she also received a medication refill slip on Patient B. It included Patient B's name and type of medication. Update: 04/04/11:Patient B will recieve a letter…

Outcome: The patient mailed back the information. The privacy officer worked with the Pharmacy to ensure that the responsible employee was made aware and educated in relation to ensuring that information is labeled correctly and mailed to the appropriate patient. In…

Issue: An employee viewed her father's electronic medical record without a need to know. Her father is a Veteran. The Privacy Officer and Alternate Privacy Officer met with the Labor / Employee Relations Specialist regarding the incident and our findings. He…

Outcome: Labor relations is not addressing this breech with the employee and the employee supervisor as indicated in the "discovery" notes.

Issue: A VA employee found a three (3) page Podiatry appointment list on the stairs leading to the parking garage. Update: 03/28/11:The list was found in area accessible to all staff and visitors. The list included full names, partial SSNs, and…

Outcome: A Privacy Violation Memo was sent to the Business Manager. To minimize this risk and as a resolution, the PO advised documents containing PII and/or PHI remain within the area they are being utilized. They should not be taken with…

Issue: Veteran A was given Veteran B's lab work results at a Community Based Outpatient Clinic (CBOC). Veteran A's wife returned Veteran B's lab work results to the CBOC. Update: 03/17/11:Veteran B's full SSN was included on his lab work document.…

Outcome: Employee was counseled.

Issue: A nurse reported that a folder containing a patient schedule that was left unattended in a patient treatment room is now missing. The list contained the name, SSN and appointment times for 8 patients. The nurse indicated a patient was…

Outcome: The employee has been reeducated about proper safeguarding of PHI. Service line has also been advised to provide a lockable drawer or cabinet that can be utilized for securing documents in the patient exam room.

Issue: The clinic manager from a Community Based Outpatient Clinic (CBOC) reported that an employee gave Veteran A's prescription information to Veteran B. The information included Veteran A's full SSN, name, medication list, and date of birth. Veteran B took the…

Outcome: The CM letter has been sent. Employees have been counseled about performing proper QA measures when providing prescription information.

Issue: Veteran A signed a Release of Information (ROI) request for a bone densitometry report. The exam on Veteran A was completed on 3/4/2011. Veteran A received Veteran B's report from an exam dated 3/08/2011. Update: 03/14/11:Veteran B will receive a…

Outcome: WILL PROVIDE TRAINING AND EDUCATION TO STAFF.

Issue: Veteran A received Veteran B's lab work results in the mail. Update: 02/10/11:Veteran B will receive a letter offering credit protection services.…

Outcome: Supervisor discussed this issue with staff. Supervisor is looking into phone system solution to mitigate this type of clerical error.…

Issue: The Privacy Office (PO) was making rounds on 3 West and found a Housing and Urban Development-Veterans Affairs Supportive Housing (HUD-VASH) referral form on the floor by the door in room 322WS. The door to the room was open. Update:…

Outcome: SIGNAGE WAS PLACED AT THE DOOR TO DIRECT VETERANS AND STAFF TO THE CORRECT LOCATION OF THE HUD-VASH OFFICE. DOOR IS NOW LOCKED AT ALL TIMES.