VA Healthcare - VISN 4 (VISN 4)

Issue: A Veteran called and stated that he had received an appointment letter in the mail for an X-ray that he had scheduled and in the envelope was another Veteran's letter. The letter contained Veteran B's name, address and appointment information.…

Outcome: 03/06/2012 - The responsible staff were re-educated on the procedure.

Issue: A clinical provider accidentally gave Veteran A's discharge summary to Veteran B. Update: 02/22/13:Veteran B will be sent a letter offering credit protection services.…

Outcome: The Supervisor believes this incident occurred due to the reuse of a chart jacket that had a previous patients information on it. As corrective action, the Supervisor advised staff to use two identifiers prior to documenting and the medical support…

Issue: Veteran A was given Veteran B's discharge instructions by mistake at the time of Veteran A's discharge from inpatient status. Update: 02/13/13:Veteran B will be sent a letter offering credit protection services.…

Outcome: PO instructed Nurse Manager to speak with Nurse who made the error and educate her as to correct policies and procedures to follow when providing discharge instructions, including , especially need to check and recheck patient's name, identity bracelet, etc…

Issue: On 02/06/13, Veteran A received medication in the mail intended for Veteran B. The Veteran took the medication without reading the label, in addition to other medication that was prescribed. He did have some side affects possibly due to taking…

Outcome: USPS delivered the wrong medication to the Veteran and each member has spoken with the pharmacy to make sure that the medications are correct. Notification letter was sent out April 9, 2013 and uploaded.

Issue: The Release of Information Office received a package from the USPS which contained medical documents that were found loose in the mail or damaged by mechanical processing equipment. The original package that was sent form Release of Information via certified…

Outcome: A claim was submitted to the USPS, and we will be contacted if the missing records are found at some point.

Issue: A Veteran reported to an outpatient VA clinic today and submitted a document that pertained to another Veteran. Several weeks ago this veteran was provided a future appointment reminder document which pertained to another Veteran. This Veteran was turning this…

Outcome: Clinic supervisor re-educated staff about double checking documents provided to patients.

Issue: The Release of Information (ROI) office sent a copy of paper records in with another release. Veteran A received Veteran B's copy of paper records. Veteran B's name and protected health information (PHI) was disclosed. Update: 02/01/13:Veteran B will receive…

Outcome: Staff was educated on double checking envelopes when mailing.

Issue: A prescription for Veteran A was sent to Veteran B. Veteran B's name, address and medication information was disclosed. Update: 02/01/13:Veteran B will receive a HIPAA letter of notification.…

Outcome: Pharmacy staff was reminded to double check envelopes when mailing.

Issue: Veteran A was mailed a laboratory report meant for Veteran B. The report contained Veteran B's full name, full SSN and lab results. Update: 01/28/13:Due to full SSN and medical information being disclosed, Veteran B will be sent a letter…

Outcome: Original records were returned to the Release of Information Office. Release of Information staff have been re-educated regarding the importance of double checkingwho the records are being disclosed to. Quality assurance process is in place.…

Issue: VA employee A inappropriately accessed the record of VA Employee B. This access occurred on the day VA Employee B had an a medical emergency while on duty. Update: 01/23/13:Employee B will receive a notification letter.…

Outcome: The employees user access was immediately disabled. The employee was required to re-sign the VA National Rules of Behavior. Service Line Management submitted a copy signed by the employee and requested user access to be re-enabled. The employees user access…