VA Heartland Network (VISN 15)

Issue: On 07/15/11 at 5:00 PM housekeeping employee found 3 folders on a table adjacent to the main entrance to the hospital. Housekeeper turned folder over to Admissions supervisor. Two folder contained pharmacy discrepancy reports, which includes inpatient name and medications,…

Outcome: Appropriate action taken by HR and service line. Letters mailed 8-19-11. Privacy officer provided re-education to employee on use and security of documents.…

Issue: SF 523-A, Disposition of Body form was found taped to the outside of the door to the facility morgue. The personal information it contained was PII of a deceased individual. Update: 07/19/11:Patient A will receive a next of kin notification…

Outcome: Responsible individual counseled by supervisor and provided addition privacy training on responsibilities of safeguarding sensitive information

Issue: The end of shift report for one of the hospital wards was enclosed with the discharge documents for Veteran A. The report included the protected health information (PHI) of seven other Veterans. Veteran A returned the documents to VA via…

Outcome: PO will attend next staff meeting to review privacy issues and answer questions.

Issue: The deceased Veteran A's daughter contacted the St. Louis VAMC claiming to have Veteran B's discharge instructions in her possession. She indicated that she would only return the documents if the VA was willing to forgive her father's medical bills…

Outcome: Privacy Officer conducted Privacy Awareness counseling/training for administrative and clinical employees assigned to specific ward.

Issue: Veteran A called to report receiving a package of medication in the mail that he had not ordered. Veteran A is not getting medications from this medical center or being actively seen as a patient at this time. Veteran As…

Outcome: Verification was made with the callers address and found that the same address and one of the three phone numbers listed was on the wrong patients profile. This address was changed by HAMR staff.…

Issue: Veteran "A" information was miss-mailed to Veteran "B". Veteran "B" physically returned the letter the next day. The letter was a 1010 EZ Health Beneficiary Form and contained information about Veteran "A" and his family. The letter is now in…

Outcome: Supervisor has provided education to the employee who made the mailing error and reminded other staff members to use caution when mailing sensitive information. Credit monitoring letter has been mailed to the Veteran. Issue is considered closed at the local…

Issue: A VA Provider shared a patient's medication list with the patient's family member who accompanied the patient to the primary care appointment. The Provider did not ask the patient's permission to do so or request that the patient sign an…

Outcome: On-going Privacy Education and Tips for Providers added to monthly PO duties. Clinic and Provider involved in incident received priority training/notification. Focus on when to release verbal and written documentation to caregivers.…

Issue: Patient A was given his outpatient routing slip for informational purposes following an appointment. Attached to it was another Veteran's routing slip. The other routing slip contained the Patient B's full name, full SSN, home address, home phone number, medication…

Outcome: Responsible employee counseled and provided additional training on their responsibilities. Information has been destroyed.…

Issue: A VA employee gave Veteran A's travel voucher to Veteran B. The travel voucher was not accepted at the Travel Office and Veteran B was sent back to clinic where he received the wrong voucher. Incident occurred on 04/19/11, and…

Outcome: Redacted credit monitoring letter attached. Appropriate disciplinary action taken. PO provided training to staff of this service line. Employee re-educated by supervisor and PO…

Issue: A photo identification (ID) card was given to Veteran A with Veteran B's personal information displayed on it. The facility is attempting to contact Veteran A to have the ID returned and the information corrected. The personal information included Veteran…

Outcome: Employee responsible for incident has been counseled and provided additional education on the responsibilities of the position