VA Heart of Texas Health Care Network (VISN 17)

Issue: The medication for Veteran A went to Veteran B. The address on the package was correct and the medication was correct (same as the other Veteran A), but the name on the medication bottle was for Veteran A. Update: 02/27/13:Veteran…

Outcome: All employees reminded to do QA checks to ensure names and address matches on outgoing mails. (contents and envelops).Notification letter sent. (attached)

Issue: A Veteran's Medicare card was given to another Veteran. The card contains the veteran's full name and full SSN. Update: 02/22/13:One Veteran will be sent a letter offering credit protection services.…

Outcome: Credit monitoring letter attached. Employees reminded to ensure information is disclosed to the correct person.…

Issue: Patient A picked up Patient Bs medication on February 8th from the Pharmacy. Patient A returned the medication on 2-14-13 to Pharmacy and did not take any of medication (verified by Pharmacist). The medication was mailed to Patient B on…

Outcome: Staff re-educated.

Issue: The ISO reported that they had been contacted by a Prosthetics staff member who was reporting a contracting officer had faxed 123 pages of information belonging to two Veterans, containing the full SSN, Home address, telephone number and miscellaneous medical…

Outcome: The information was retrieved from the vendor and destroyed. The employee who caused the error was required to complete Privacy and HIPPA training for educational purposes. Credit monitoring letters were completed and forwarded to the Veterans that were affected by…

Issue: An ex VA Nurse was at NCFC with her husband at an appointment. While in the room, the Provider received a phone call and he looked up another patient in CPRS. He left the room with the other patient's information…

Outcome: Employee received a written counseling .

Issue: The Privacy Officer (PO) was contacted by the Patient Advocate who was reporting that a Veteran was present who had been provided a copy of another Veterans' DD214. The PO met with the Veteran and retrieved the information. The Veteran…

Outcome: The employee that was identified as improperly disclosing PHI to the wrong Veteran was educated and trained on the proper way to release information. The Alternate PO provided the employee with Fact Sheet, Volume 09, No. 5, Disclosure of Protected…

Issue: Veteran A reported to a clinic appointment today with Veteran B's appointment list. Appointment list from 12/31/12 was printed by a Medical Administration Service clerk on that date and was given to the nurse today by Veteran A. Update: 02/05/13:Veteran…

Outcome: The employee that released the information has been provided education on the importance of verifying that the correct appointment information is provided to all Veterans. The Alternate PO finds that this was a preventable incident and request that the Supervisor…

Issue: After requesting and receiving a Sensitive Patient Access Report (SPAR), the Non-Veteran employee is requesting an access justification by two employees. Update: 03/07/13: The Non-Veteran employee will receive a HIPAA letter of notification.…

Outcome: After interviewing both employees the Privacy Officer (PO) has determined that these accesses were inappropriate as they were not for treatment, payment, or healthcare operations. The PO provided both employees with a copy of Privacy Fact Sheet, Volume 09, No.…

Issue: After requesting and reviewing a SPAR report. The Employee/Veteran is requesting a justification for the access of their medical record. Update: 02/22/13:One employee will be sent a HIPAA notification letter.…

Outcome: Alternate PO has completed fact-finding investigation. Employee was provided a copy of the Rules of Behavior for Employees. The Alternate PO requested that the employee immediately complete VHA Privacy and HIPAA Training FY13.…

Issue: A VA Pharmacist was preparing two different bags of prescriptions when he put a bottle of Veteran A's prescription into the bag for Veteran B. Veteran Bs wife left the facility with the bag without noticing. The VA Pharmacist noticed…

Outcome: On 12/20/12, additional training/counseling took place. Step by step procedures were discussed to be used to prevent misplacing of finished medication when filled and bagged prescriptions must be worked on.…