VA Mid-Atlantic Health Care Network (VISN 6)

Issue: Veteran A received Veteran B's medical records. Veteran A returned the records via mail to the Director's office. The records contained Veteran B's name, address, full SSN and diagnosis. Update: 05/02/11:Veteran B will receive a letter offering credit protection services.…

Outcome: ROI staff has been re-educated in the importance of verifying document prior to mailing.

Issue: Veteran A was given a list of appointments. When he showed up for the appointment, he learned that the appointment list that he received was for Veteran B. The appointment list contained Veteran B's name and full SSN. Update: 04/27/11:Veteran…

Outcome: Supervisors provided training to all staff that worked in that clinic.

Issue: A Beckley VAMC staff physician was asked to write a letter describing a Veteran's present medical condition. This Veteran is presently an inpatient at Beckley VAMC. This letter was requested by two of the adult sons of the Veteran. However,…

Outcome: This event was discussed at length with both the physician and the new resident. It was the new medical resident who provided the document. Appropriate education was provided, including privacy training. The physician and the medical resident discussed this event…

Issue: A Pharmacy Technician dispensed medication to Veteran A and included a medication for Veteran B in Veteran A's package. Veteran B's name and medication type were disclosed. Update: 04/26/11:Veteran B will be sent a notification letter.…

Outcome: All clerks assigned to this function have been re-trained. Practice has been discontinued.…

Issue: Patient A came in for a nurse appointment on 04/12/11 and gave the nurse a medication list that he received in the mail. The medication list was for Patient B and was printed on 04/05/11. It is believed that the…

Outcome: Since the Privacy Officer was unable to determine who the responsible party was, all employees at the CBOC were educated on safeguarding information.

Issue: The spouse of a Veteran A called the Director's Office stating that Veteran A's information had been mailed to Veteran B. The information mailed were test results for a procedure done at this facility. Both Veterans had the same procedure…

Outcome: The machine was recalibrated and mail room staff will continue to review a sample of letters ready to be mailed.

Issue: A Veteran (Veteran A) received another Veteran's (Veteran B) medication in the mail. Update: 04/04/11:Veteran B will be sent a notification letter.…

Outcome: Health Administration Service employees were reminded to be careful when selecting a patient record and entering patient demographics into VISTA/CPRS patient records.

Issue: A VA employee found progress notes outside the hospital near the parking lot and close to a truck that was shredding documents. It was one Veteran's medical information, including their full SSN. Update: 04/05/11:Veteran A will be sent a letter…

Outcome: Staff are reminded regularly to be careful when handling patient information.

Issue: Suspicious actions involving an employee's access to a Veteran's ID card. There was an investigation performed by the VA Police. The employee denied having access to the ID card however after a search of the area, the ID card was…

Outcome: The VA police and HR are still investigating this incident. No other information is available at this time. Please close this ticket.…

Issue: A medical resident left the cafeteria after eating her lunch and left behind progress notes on three (3) psychiatric patients. This occurred around 2:15 p.m. An employee of the Office of Information and Technology (OI&T) noticed the documents when he…

Outcome: The provider (resident) who left 3 documents with patient information on the table in the cafeteria was counseled and asked to retake the VA Privacy and Information Security Awareness training. Training was completed by the provider as requested and promised…