VA Mid-Atlantic Health Care Network (VISN 6)

Issue: Veteran A was given an appointment list from clerk. When the Veteran A went home he observed that the list of appointments were not for him but another Veteran (Veteran B). Update: 02/16/11:Veteran B will receive a letter offering credit…

Outcome: General education to group of clerks.

Issue: VA employee mailed eligibility information belonging to Veteran A, to Veteran B. Update: 01/31/11:Veteran A will be sent an offer for credit protection services.…

Outcome: Letter offering Credit Protection sent to the Veteran.

Issue: Veteran A was inadvertently provided Veteran B's diabetic testing kit RX at the Pharmacy window. The last names are the same and the first initial off the first name begins with the same letter. The busy Pharmacy technician, in error,…

Outcome: The RX (diabetic test kit) that was inadvertently issued to the wrong patient is now in possession of the Beckley VAMC Pharmacy. Please note that the veteran information that the Pharmacy prints on paperwork that accompanies prescriptions is only the…

Issue: Employee was given a notice of termination that included a veterans name and social security number Update: 01/25/11:Veteran will receive a letter offering credit protection services since his full SSN was exposed and the employee had received their notice of…

Outcome: Credit Monitoring letter uploaded.

Issue: On 1/19/11, an HBPC NP, PharmD and a pharmacy student were making joint visits to HBPC patient homes. The PharmD brought paperwork for two patients with the intention of having the student review notes during the car ride so specific…

Outcome: Manager has taken immediate action and has reviewed policies and procedures with staff involved.

Issue: Veteran had an appointment list after leaving appointment with primary care provider. Update: 01/14/11: PO states there weres eight names on the list. The list did not leave the facility and was returned to VA employee custody in less than…

Outcome: Staff and Supervisors reminded of precautions to take and responsibility for timely reporting of incidents.

Issue: Veteran A received Veteran B's letter in addition to his own which included name and PHI. Update: 01/06/11:Veteran will receive a letter of notification.…

Outcome: Talked with provider, nurse and clerks from area that the letter came from. Need to double check for single letter included in each envelope.…

Issue: Beckley's VAMC's travel clerk cannot locate six completed employee travel packets. Each individual packet contains a completed SF 182 as well as either Attachment A or C to the SF 182, the employees travel itinerary and a completed employee expense…

Outcome: The employee responsible has received training. Additionally, this incident has certainly heightened her awareness of how easy it is to accidentally shred documents that do not require shredding. Some of the routine office procedures have also been changed, in that…