VA Heart of Texas Health Care Network (VISN 17)

Issue: Veteran contacted the Privacy Officer to report that after requesting receiving and reviewing a Sensitive Patient Access Report (SPAR), she is questioning the access of a VA provider on the dates of May 24, 25 and August 11, 2011. The…

Outcome: The PO has determined that the employee printed a progress note from the EMR without authorization, and accessed the medical record of the Veteran not for the purpose of treatment, payment or healthcare operations. The PO provided the employee with…

Issue: Patient went to the Pharmacy to pick up meds ordered from the Emergency Department (ED). When the Pharmacist looked at his discharge paperwork, he realized it didn't belong to the patient he was assisting. The patient didn't realize it wasn't…

Outcome: Staff was re-educated.

Issue: A Veteran was handed medication at Pharmacy window, he immediately noticed the name on the prescription was not his and he returned the medications right away. Update: 02/09/12:One Veteran will be sent a letter of notification.…

Outcome: Pharmacy staff were re-educated.

Issue: A VHA staff member changed the address on the wrong veteran (same first name, same last name, different SSN). Because of the wrong address on file, CMOP mailed the prescriptions to the wrong individual. Update: )2/03/12:The Veteran whose information was…

Outcome: Staff member re-educated.

Issue: Employee A received an email from Employee B with an attachment that contained a copy of a screenshot disclosing last name, first name and full SSN of another employee that was not intended for Employee A to receive. Update: 01/13/12:One…

Outcome: Sender was contacted by Facility ISO and was brought to their attention/awareness of this inadvertent disclosure.

Issue: Veteran A received his medications via mail. When Veteran A went over his medication package, he noticed a medication label that belong to Veteran B consisting of his last name, first name, physical address and name of medications (2). Veteran…

Outcome: Pharmacy Supervisor will reeducate/retrain employees on the importance of Patient Identification and verification prior to handling and dispensing of medications to prevent re occurrence in addition to taking extra steps by rechecking the final bagging to ensure correct packaging. Notification…

Issue: Veteran A received a Fee Basis Authorization Letter belonging to Veteran B that consisted of Veteran's B last and first name, last four of SSN, home address and Medical Diagnosis. Update: 01/06/12:Veteran B will be sent a notification letter.…

Outcome: Supervisor will be conducting a mandatory training on importance of Patient Identification Policy and verification within 2 weeks to their employees. Notification Letter has been mailed to Veteran.

Issue: A female patient reported being inappropriately contacted via her cellular phone and received text messaging multiple times by a male VA employee. The patient allegedly reports that the VA employee accessed her medical record to obtain her personal phone number.…

Outcome: The employee resigned.

Issue: Veteran B had not received his medications. When he contacted the Pharmacy, the Pharmacist realized that his medications had been handed to Veteran A at the Pharmacy window. The informaiton disclosed incuded Veteran B's name and medication type. Update: 01/02/12:Veteran…

Outcome: Pharmacy staff re-educated.

Issue: Veteran A presented to the office today with an appointment listing for Veteran B. Veteran A alleges that on 12/17/11, upon his discharge from 4South, he requested a copy of his future appointments. He claims that the employee (no name)…

Outcome: Staff re-educated.