VA Heartland Network (VISN 15)

Issue: Veteran A's diagnostic results were erroneously incorporated with Veteran B's mail. Upon discovery, Veteran B contacted this facility's VFW representative and returned the paperwork to him. The VFW representative, in turn, gave it to the Privacy Office. Update: 05/08/12:Veteran A…

Outcome: Spoke with supervisor of section responsible for incident. Supervisor shared information with all employees to ensure such actions do not reoccur. Notification letter sent to affected Veteran.…

Issue: Veteran A received a medication summary routing slip belonging to Veteran B. Veteran A returned the document within 30 minutes. Veteran A states he was given the document by a physician in the clinic. Veteran A returned the document to…

Outcome: The PO provided education to employee. All other actions wil be handled by Human Resources (HR) and the employee's Service.…

Issue: A Pharmacy Employee mailed medications for Veteran A. Included in mailing were medications for Veterans B, C and D. Veteran A telephoned the pharmacy to report the prescription error. A Mailer has been sent to Veteran A to return medications.…

Outcome: PO provided re-education on mismailing and patient information to employee. The service is instituting a new process to lessen possible reoccurrence of this matter.…

Issue: Employee A sent a mass email requesting leave donations for Employee B. The protected health information (PHI) of Employee B was disclosed. Employee A does not have PKI, however he s current on privacy training. Update: 05/07/12:Employee B will be…

Outcome: Education was provided to employee by PO.

Issue: Employee health nurse is setting up appointments for new employees. The nurse is telling other staff members that the employee is coming in to obtain a physical, a tour of the building, etc. Update: 05/01/12:The employee will be sent a…

Outcome: Education was provided to employee.

Issue: Veteran A's Outpatient Routing Slip was given to Veteran B along with Veteran B's personal information Update: 05/01/12:Veteran A will be sent a letter offering credit protection services, due to full name and full SSN being disclosed.…

Outcome: Responsible employee counseled by supervisor and Privacy Officer concerning responsibilities of handling sensitive information. Credit protection letter sent to affected Veteran.…

Issue: A clerk changed a home address of a patient and it was wrong, thus his medications were sent to the wrong address. The medications were mailed out from Consolodated Mail Out Pharmacy and here from our facility. Update: 04/27/12:The Veteran…

Outcome: Education was provided to clerk staff as they were using a short cut key that inadvertently placed the Veteran's information into another Veteran's chart.

Issue: A Veteran's medication refill information was faxed to the wrong fax number. That iincluded the Veteran's name, address, full SSN and medication information. Update: 04/24/12:One Veteran will be sent a letter of notification.…

Outcome: CBOC employees instructed in correct faxing procedures by PO. Process reviewed. Verbal counseling by Supervisors.…

Issue: Veteran A returned medical record documents from Veteran B's medical record that he had received in mail along with copies of the medical documents he had requested. Update: 04/19/12:Veteran B will be sent a letter offering credit protection services.…

Outcome: Employee counseled by Supervisor and Program Manager, procedures reviewed for improvement.

Issue: Veteran A brought medications to the facility that were mailed to his home. Veteran A received five packages each addressed to him. Only one mailer contained Veteran A's medication. All other mailers and medications dated 02/25/12 were for four other…

Outcome: Notification letters mailed. Service staff is working on improving mailing process to prevent this type of occurrence.…