VA Healthcare - VISN 4 (VISN 4)

Issue: ELECTRONIC OPF INFORMATION WAS PLACE IN ANOTHER EMPLOYEES OPF RECORD. THAT EMPLOYEE FOUND THE INFORMATION AND REPORTED IT TO THE HUMAN RESOURCE DEPARTMENT. Update: 02/10/11:Employee will receive a letter offering credit protection services since their full SSN and DOB was…

Outcome: HR to provide additional training to staff to verify the records are in the correct file before scanning to eOPF. ISO requests ticket be closed once redacted letter uploaded by Privacy Officer…

Issue: A VA employee planning to use a government vehicle found a packet of information containing patient names, SSNs, and appointment dates. The preliminary investigation determined that the packet had been left in the vehicle by another employee on 10/26/10. Update:…

Outcome: The employee was educated on this incident and re-educated on the importance of making sure all information is taken out of the vehicle when exiting

Issue: Patient A contacted Pharmacy Call Center reporting that he had a bottle of medication belonging to Patient B. Both patients had prescriptions for the same medication and strength filled here in Lebanon on 12/22/10 at separate times. Supervisor cannot be…

Outcome: Staff educated and new perscription mailed to patient.

Issue: misdirected mail with full SSN, not found. Update: 01/18/11: Due to the fact that the originial mail was not loctated, Veteran A will receive a letter offering credit protection services.…

Outcome: ROI supervisor and staff counseled for attentiveness to the possibility of multiple addresses in ROI system and need to reference the active request for current information.

Issue: Patient received the medication intended for his uncle. He noticed it was not his medication due to the types of medication and notified the Pharmacy. New meds were sent to the correct patient. Update: 01/11/11:Patient will receive a letter of…

Outcome: The resolution is that new meds were sent to the patient. Although the staff at this facility were not at fault, it has been identified that the USPS mis-delivered a medication package which had the same effects of a miss-mailed…

Issue: Six medications were mailed to the wrong veteran. The label has another veteran's name and drug on it. Update: 01/06/11:Veteran B will receive a notification letter.…

Outcome: The pharmacy staff was educated on the issue. A notification letter is being sent to the vet.…

Issue: Mis-mailed medication. Packaging contained the full name, medication and address of the patient. Update: 01/05/11:Veteran will receive a letter of notification.…

Outcome: Notification Letter sent to Veteran on 1/6/2011

Issue: Patient went to see a Dermatologist and stated there was absolutely no privacy or confidentiality during the entire visit, particularly pertaining to the examination and information exchange. Update: 01/04/11:No data breach occurred.01/10/11:Upon further investigation, this was a privacy breach. The…

Outcome: Corrective action taken, retraining.

Issue: Patient A received prescription for Patient B. Patient B notified the LVAMC and sent back the prescription VIA UPS. LVAMC is received the package and destroyed the meds. Update: 01/04/11:Patient will receive a letter of notification.…

Outcome: Notification Letter sent to Veteran on 1/6/2011

Issue: Prescription was mis-mailed to a patient with the same first and last name, however, different last 4. The Veteran that received the medication is supposed to be returning them to LVAMC on 1/13/11. Update: 01/04/11:Patient will receive a letter of…

Outcome: Notification letter sent to Veteran on 1/6/2011