VA Heart of Texas Health Care Network (VISN 17)

Issue: Medication belonging to Veteran A was inadvertently mailed to Veteran B due to incorrect mailing address posted on Veteran A's demographic information. Last name and first name disclosed on Medication bottle. Update: 07/05/11:Veteran A will be sent a notification letter.…

Outcome: Mitigation was sent to Chief of MAS at Valley Coastal Bend HCS to get in touch with Chief of MAS in STX for corrective action regarding demographics. HIPAA Notification letter was completed and sent to Veteran regarding disclosure of Last…

Issue: Veteran A reported to a Nursing Service Administrative Support Assistant that they had been receiving Veteran B's appointment letters and billing information via mail. The letters included Veteran B's date of birth. He also stated that he had been contacted…

Outcome: Credit Monitoring Letter provided to the veteran, and employees will be counseled to reduce errors in mailings.

Issue: Veteran A's DD214 was scanned into the wrong Veteran's record. Both Veteran A and Veteran B have same name but different SSNs. Release of Information (ROI) clerk did not check SSN on the DD214 prior to handing to Veteran B.…

Outcome: Employees were counseled, File Room staff were re-educated on ensuring information is scanned into the correct patients files in CPRS and ROI was told to verify patient prior to handing to requestor.…

Issue: Employee A was picking up information off a printer for Veteran A. Employee A unknowingly also picked up additional information regarding Veteran B from the printer. When Veteran A got home, he discovered the additional information and called the triage…

Outcome: AO has discussed situation with employee A and explained when retrieving printed information, she must carefully ensure that she takes only the information printed by her. The individual who printed the other information will have a separate printer networked for…

Issue: A Resident left her patient list in the Canteen. She put the list on the counter when she was paying for her food and forgot it. As soon as she realized it was missing, she went back but by then…

Outcome: The employee was counseled by their supervisor.

Issue: Veteran B picked up medication at clinic window and it also contained medication for Veteran A. When Veteran A went to clinic to pick up medications, the incident was discovered. Veteran B was notified by phone message and returned medication…

Outcome: Pharmacist and Pharmacy technician were verbally counseled by Pharmacy supervisor on the importance of dispensing the correct medications to the correct patient. Pharmacy personnel responsible for window dispensing will check all medications against paperwork prior to dispensing to ensure correct…

Issue: Patient A received Patient B's medication. Patient returned the medications to the Pharmacy on the day of receipt. Update: 04/29/11:Patient B will receive a letter of notification.…

Outcome: Pharmacy staff re-educated.

Issue: The Patient Advocate reported that he had received an email message from Veteran A who reported that he received a parcel from the Temple VA Release of Information (ROI) office that contained the medical information Veteran B. Veteran A had…

Outcome: This process has been changed to where the ROI section is no longer is allowed to use UPS provided boxes that come pre-labeled. Staff has been educated on the importance of verifying that the correct information is packed for shipment.

Issue: Veteran A received a fee authorization for Veteran B in the mail at his home. The information disclosed included Veteran A's full name, last four digits of the SSN, treatment authorization, reason for visit (cardiology exam), and referring physician name.…

Outcome: Veteran A returned the incorrect fee authorization to VHA. Privacy notification letter sent to Veteran B. Employee will retake privacy-security training. Employee will be verbally counseled by supervisor. All fee staff will be told to be more careful when mailing…

Issue: Veteran patient wrote a fourteen (14) page complaint concerning his care and providers and requested this information be scanned into his Electronic Medical Record (EMR). Two months later, the Veteran submitted a Release of Information (ROI) request for this fourteen…

Outcome: VA was not at fault. Patient's wife picked up copy of ROI requested and lost by UPS. Credit monitoring letter sent to Veteran.