VA Healthcare - VISN 4 (VISN 4)

Issue: On 12/20/12, Veteran A, who resides in the Domiciliary (DOM), opened up his medication bag and found medication for Veteran B, who also resides in the Domicilary, in his bag. The medication was actually picked up from the pharmacy on…

Outcome: Butler Pharmacy will no longer be allowing staff to add prescriptions to existing batches. The ScriptPro system has a flaw that will allow 2 patients to be combined in a batch. This also extends to adding controlled substance scripts to…

Issue: Veteran A reported to the Patient Advocate that he felt his son was accessing his medical record based on comments he made to him. Update: 12/14/12:Veteran A will be sent a notification letter.…

Outcome: Access will be restricted today until the investigation is completed. PO working with LR/ER in relation to actions that will be taken as a result of the breach.…

Issue: Veteran A reported that Veteran B's prescription leaflet containing Veteran B's full name, address and medication information was included with Veteran A's mailed medications. Update: 12/03/12:Veteran B will be sent a notification letter.NOTE: There were a total of 79 Mis-Mailed…

Outcome: The leaflet has been retrieved by the Pharmacy Service. Pharmacy Staff has been re-educated regarding the importance of protecting patient information at all times. Quality control measures are in place in the Pharmacy Service. The HIPAA notification letter has been…

Issue: A Veteran's medical information that contained 7332 diagnosis was released to the Office of Area on Aging without the Veteran's proper consent being completed. Update: 11/29/12:One Veteran will be sent a letter of notification.…

Outcome: Staff were reminded on the importance of securing personal patient identifiable information.

Issue: The VA mismailed a fee basis approval letter with authorization attached. Veteran A got Veteran B's information, including his name, address, partial SSN and diagnosis. Update: 11/07/12:Due to date of birth and medical information being exposed, Veteran B will be…

Outcome: Employee was educated in mail processes and asked to retake the Privacy and HIPAA training as part of education. Supervisor notified of incident.…

Issue: A Human Resources staff member forwarded an email to the education office and to a local community college. It was not delivered to the community college due to an error in the address. Attached to the email was a health…

Outcome: EMAIL WAS DELETED BY COMMUNITY COLLEGE STAFF MEMBER.SUPERVISORS REVIEWED PROCDURES WITH EMPLOYEES AND REAFFIRMED THE IMPORTANCE OF DOUBLE CHECKING WHAT INFORMATION IS ATTACHED TO EMAILS. REVIEWED PKI PROCDURES WITH THEM.

Issue: Patient seen in SPU at which time they signed the imed consent form for another patient. patient then proceeded to the MSA Clerk for travel. At that time the Clerk identified that there were concerns such as there were no…

Outcome: Staff education was conducted.

Issue: The ISO issued an audit log on 10-29 to the Chief of Medical Services to validate access. The access in question was that of a physician accessing other physicians (patients) records at the VAMC. Once the Chief of Medical service…

Outcome: Medical Service Chief is working with LR/ER to address.

Issue: A veteran received another veterans medication. Update: 11/02/12: One Veteran will be sent a leter of notification.…

Outcome: Both one on one education was conducted by the Pharmacy Supervisor with the employee. In addition, this was discussed with all staff at a broad level.

Issue: Veteran A called in and reported that he had received an authorization for outpatient services letter, and the letter contained the name address and full SSN of Veteran B. Update: 10/31/12:Veteran B will receive a letter offering credit protection services.…

Outcome: CM leter sent out, staff reducated about proper quality assurance measures.