VA Healthcare - VISN 4 (VISN 4)

Issue: Employee A's yearly evaluation was scanned into employee B's EOPF file. Update: 10/29/12:Employee B will be sent a general notification letter.…

Outcome: The HR department was to educate the employees doing uploads on the importance on double checking whose information is going into what employee file.

Issue: A Refrigerated prescription that was intended for Patient A inadvertently was packed and mailed to Patient B who later received insulin (aspart & glargine) inappropriately. The incident was reported by Patient B. A replacement prescription was then sent to Patient…

Outcome: The pharmacy staff was educated on double checking items before placing them in the mail.

Issue: A Veteran's address was changed in error in the system and medications were sent to the wrong address Update: 10/22/12:The Veteran will be sent a HIPAA notification letter.…

Outcome: Investigation 10/24/12-credit monitoring letter sent request final review and case closed. The address has be corrected and the employee was counseled.…

Issue: Veteran A inadvertantly received Veteran B's paperwork and medication. Once he discovered the error, Veteran A retruned the medication to the phamrmacy. Update: 10/22/12:Veteran B will be sent a notification letter.…

Outcome: Staff counseled and trained. Credit monitoring letter sent.…

Issue: A Veteran called in and reported that when he left a medical appointment today, he was given some discharge paperwork. When the Veteran got home he discovered mixed in with his documents a list of names and SSNs that appeared…

Outcome: All Primary Care staff will review Privacy and HIPAA training. This information regarding keeping patient information secured, and the importance of ensuring proper information is released to Veterans will be discussed in upcoming staff meetings.…

Issue: A medical record request was received and processed. When the Release of Information clerk sent out the documents they sent the wrong documents out to the requestor. the documents pertained to Veteran B with same last name and similar first…

Outcome: Records were destroyed, staff are being reeducated about proper QA and name validation.

Issue: Veteran A's medical records were inadvertently included with Veteran B's records when both Veterans requested copies of their medical records. The records included Veteran A's name, address, full SSN, date of birth, and protected health information (PHI) Update: 09/28/12:Veteran A…

Outcome: Staff educated and counseled about preventing this type of incident.

Issue: Veteran A information was sent from the Release of Information office to the wrong attorney's office. Information released was full name, full social security number, full date of birth, diagnoses information, medications, and lab information. Veteran A expired on 5/26/11.…

Outcome: Supervisor will counsel employee on the importance of safeguarding personal patient identifiable information.

Issue: Veteran A received a package in the mail addressed to Veteran A. It contained Veteran's A prescription and paperwork. It also contained Veteran B prescription. There was a violation of Veteran B's full name and medication name only. Update: 09/27/12:Veteran…

Outcome: Pharmacy staff were reminded on the importance of safeguarding personal patient identifiable information.

Issue: A Veteran contacted the Clinic asking for pain medications. The information was gathered by the Clerk and then passed onto the Nurse. The Veteran gave his name and last four digits of his SSN to the Clerk. The Nurse contacted…

Outcome: Supervisors rounded the Clinics on 9-21 reminding staff about privacy in relation to giving information over the telephone.