VA Mid South Healthcare Network (VISN 9)

Issue: On 09/15/12, an employee at the Nashville Campus found a dietary label on the floor by the service elevators near the GI lab on the second floor. The dietary label contained a Veteran's last name, ward location (2G), and dietary…

Outcome: 10/1/12: Nutrition and Food staff were re-educated on the importance of safeguarding PII when transporting food trays. HIPAA notification letter mailed.…

Issue: Veteran As daughter contacted the Privacy Officer, Nashville Campus, regarding the following concern: On 09/07/12, Veteran A was seen in Pacemaker Clinic and Advance Heart Failure Clinic (Nashville Campus). Upon completion of the appointment, Veteran A was given paperwork to…

Outcome: NP will be educated on the importance of utilizing ROI for records request and checking documents for accuracy before mailing. 9/20/12 - NP was educated as indicated above. CM letter mailed.

Issue: A medication list belonging to Patient A was given to Patient B. Patient B discovered the error and returned the document. Update: 09/13/12:Due to full SSN and medical information being disclosed, Veteran A will be sent a letter offering credit…

Outcome: Staff reminded to use caution when handling documents with PII/PHI.

Issue: An envelope was returned to the facility that had a label with a patient's name, full SSN and DOB affixed to it in place of an address label. The envelope had been franked by the local mail sorting facility but…

Outcome: Staff reminded to use caution when handling documents with PII.

Issue: The Pharmacy dispensed medication and gave the medication to the wrong patient. The pharmacy immediately called the patient upon discovering this. The patient indicated that they had already noticed that the medication was not theirs and flushed the medication down…

Outcome: This information has been reported to the OIG, DEA as well as the police. Both patient's were made aware by the pharmacy what had happened. No one was injured due to this mistake, it was caught in time. Pharmacy chief…

Issue: The switchboard operator received a phone call from a Veteran who received a signed form from his Primary Care Physician with another Veterans form included in the letter. The form was for requesting Handicap Access and contains Veteran's name and…

Outcome: Staff reminded to be cautious when handling documents with PII.

Issue: The Privacy Officer (PO) at the Alvin C York Murfreesboro Campus was contacted by a Business Office employee who stated that Veteran A provided medical records of another Veteran to them. Veteran A informed the employee that he had requested…

Outcome: 8/29/12 - PO has obtained the medical records that were mis-mailed. CM letter completed and to be mailed on this date. PO referred incident to Chief, Business Office for the appropriate action, which will include disciplinary actions and education/training.…

Issue: Veteran A contacted Outpatient Pharmacy (Nashville Campus) to report he received controlled medication, via UPS, which belong to Veteran B. Upon investigation, the Supervisor, Outpatient Pharmacy (Nashville Campus) , found the tech (who is a new employee) printed the wrong…

Outcome: 9/5/12 - Upon inquiry, the PO learned: The Pharmacy Tech printed the wrong UPS label. The Pharmacist, who checked the order, did not catch the error. This is the first incident for both employees. Employees were educated on the importance…

Issue: Social worker called and indicated that she had faxed referral information on a patient to a private fax number instead of the Nursing home. The private individual contacted us stating that he received this information in error and wanted to…

Outcome: The employee who mis-faxed this information insured that the information was destroyed after realizing it had been faxed to the wrong location. Employee was spoken to by PO regarding the safeguarding of faxed information. To call the person/vendor that is…

Issue: Patient A registered at the admissions desk to be seen. She was registered in the system and received an armband. The patient noticed that she had the armband of Patient B, who was not being seen at the hospital. The…

Outcome: Service chief is the one who notified the Privacy Officer (PO) of this incident. The PO indicated to the service chief the employee needed to be reminded to check and cross check armbands before placing them on the Veterans. This…