VA Healthcare - VISN 4 (VISN 4)

Issue: A Veteran called in and reported that 2 letters were received from the VA and the envelopes were not sealed, and it appears that they were never sealed. The Veteran does not have any suspicion of tampering and received the…

Outcome: Mail room staff advised to do better quality assurance checks to minimize the chance of future occurrences

Issue: A pharmacy prescription was mismailed to the incorrect patient. The incorrect patient opened it up and notified pharmacy staff of the error. He informed staff that he would return the medication in March when he had another appointment. He lives…

Outcome: VA STAFF RETRIEVED THE MEDICATION. THE PO WILL MAKE A PHONE CALL TO THE POST OFFICE WHERE THE INCIDENT HAPPENED WITH GENERAL DETAILS OF THE EVENT. NO PATIENT NAMES WILL BE RELEASED…

Issue: Medication labels were sent to the incorrect patient. Update: 02/28/11:The labels included a patient's full name, address, and medications. The patient will be sent a letter of notification.…

Outcome: Spoke with Pharmacy, they are going to look at the current process and educate staff.

Issue: Pharmacy packaged prescriptions using the correct label information and the correct label on package. Warehouse staff had to ship by other means due to weight of package and processed another label , which was placed on top of original label,…

Outcome: A letter notifying the Veteran of the privacy violation was mailed to him. The pharmacy staff were reminded of the importance of double checking their label information and the package labels.…

Issue: When preparing a response for routine Release of Information to attorney of Veteran A the VHA employee erroneously enclosed the medical records of Veteran B, who also had a valid request for records. Update: 02/25/11:Veteran B will be sent a…

Outcome: Employee counseled by supervisor.

Issue: A prescription was mailed to the wrong patient. The patient name and medication were exposed to another patient. Update: 02/25/11:The patient will be sent a letter of notification.…

Outcome: A letter was mailed to the veteran notifying him of the privacy violation. Pharmacy staff were reminded to double check all labels and medication prior to mailing out packages.…

Issue: Prescription was mailed the correct patient however it possessed another patients medication and full name. Update: 02/25/11:One patient will recieve a notifiction letter.…

Outcome: Mailed a letter to veteran notifying him of the occurrence. Education to pharmacy to double check labels to be sure the medications are labeled and shipped to the correct veteran and address.…

Issue: Mis-faxed progress note Update: 02/25/11:PO states Veteran information was faxed. Someone from the general public received the information. He notified us that he received the information and stated to the social worker that he would destroy it.Veteran will receive a…

Outcome: Staff was educated on faxing procedures. Incident Response Team and supervisor notified of incident. Employee who caused the error was asked to re-take the VHA Privacy Policy training course as part of education.…

Issue: Patient information was sent to a FOIA Requestor on an incorrect patient. The Requestor returned all orginials to the FOIA Officer. Update: 02/16/11: Due to name and DOB, Veteran B will receive a letter offering credit protection services.…

Outcome: Education has been performed with employee.

Issue: Medication error occurred one patient received another patient's medications. This was a result of an employee selecting the wrong patient for the postage label. The patient full name, full address and nartotic was exposed. Update: 02/15/11:The patient whose information was…

Outcome: A double check process has been implemented into the lab due to this and other incidents.