VA Heart of Texas Health Care Network (VISN 17)

Issue: Veteran A received medication from CMOP to his address but the medication received was for Veteran B. Medication label consisted of last and first name of Veteran B, prescription number, name of medication, dose, frequency, and route for Veteran B.…

Outcome: Local Pharmacy staff notified the Consolidated Mail Outpatient Pharmacy leadership on the disclosure made at their site for review and action.

Issue: The Privacy Officer (PO) received a telephone call from Veteran A, who was reporting that he had received information pertaining to Veteran B in a letter forwarded to him from the Austin Outpatient Clinic (OPC). Included in this letter was…

Outcome: The PO investigated this incident and identified the area where this error originated. The PO has provided education to the staff and reminded them of the importance of protecting VA sensitive information.

Issue: Veteran A came to the Pharmacy window this afternoon and told Employee B he had received someone elses paperwork along with his own. Employee B reviewed everything in the bag that Veteran A presented. It included Veteran A's medications and…

Outcome: Pharmacy Supervisor will re-train and educate all staff on the importance of reviewing each and every paper for accurate patient information prior to providing medications to the patients.

Issue: The Privacy Officer (PO) was contacted by the Supervisor of the C&P section, who was reporting the loss of six volumes of C-Files that were shipped via UPS. All six volumes belong to one veteran. The tracking document shows that…

Outcome: After numerous attempts to retrieve the records from UPS, the records have not been located to date. Credit letter forwarded to the Veteran and scanned into PSETS.

Issue: Patient A received Patient B medical records. The records include Patient B's name, address, date of birth, full SSN, and diagnosis. Update: 07/19/12:Patient B will be sent a letter offering credit protection services.…

Outcome: Employee was educated and will receive disciplinary action.

Issue: Pharmacy reported that Patient A received Patients B medication. Patient A returned the medication to the Pharmacy and did not take any of the medication. Pharmacy will confirm that Patient B has received his medication. Update: 07/18/12:Patient B will be…

Outcome: The employee responsible has been re-educated on the importance of checking prescriptions before handing them over to patients.

Issue: Patient A received a fee cover letter with Patient A's appropriate name and address, but enclosed was a fee authorization letter belonging to another Veteran which includes first and last name, home address, medical diagnosis/history, medications of Patient B. Update:…

Outcome: Supervisor has reviewed the incident with staff and has reeducated/retrained on checking every cover letter and fee authorization letter before mailing to prevent incident from happening again.

Issue: A Veteran reported that she received a phone call from one of the employees informing her that he was a secret admirer. The Veteran believes that the employee got her phone number by accessing her information. Update: 07/11/12:The Veteran will…

Outcome: The employee will be sanctioned per Human Resources Service guidance.

Issue: Patient A received Patient B test results. The results included the Name, SSN, Age and DOB. Update: 07/10/12:Patient B will be sent a letter offering credit protection services due to full name and full SSN being exposed.…

Outcome: Patient was sent a notification letter and the employee who committed the error was counseled.

Issue: A VA employee suspects that a co-worker accessed her record without authorization. The report does show access, and the employee will be interviewed to determine the reason for access. Update: 07/09/12:Employee B will be sent a letter offering credit protection…

Outcome: There is no evidence that supports authorized access, thus there is a privacy violation of inappropriate acess. The case was turned over to the service Chief and HRMS. Appropriate actions taken.…