VA Mid South Healthcare Network (VISN 9)

Issue: Veteran A contacted the outpatient pharmacy at the Nashville Campus to report he received medication which belonged to Veteran B. Upon investigation, the Supervisor of the outpatient pharmacy learned the incident was due to a human error. The pharmacy processed…

Outcome: 4/2/12 - Upon investigation, the Outpatient Pharmacy Supervisor, Nashville Campus, found the incident was due to a human error. Pharmacy had inadvertently placed the wrong address label on the envelope. Veteran A returned the medication to the Outpatient Pharmacy, Nashville…

Issue: Over the weekend Contractors came in to the Spinal Cord Injury Clinic and waxed the floors. When the Social Worker arrived this morning her office door was open and items were moved around in the office and were not in…

Outcome: This incident has been investigated with the VA Social Worker who has been counseled to used reasonable safeguards to protect Veterans names and other identifiable information in her office against theft, inappropriate access and use. The PO has requested all…

Issue: On or about 2/27/12, the Nashville VA File room requested records from Neosho Kansas Records Center on two Veterans. Those records were shipped on 2/27/12 via UPS with a Tracking Number. The Package was received at the VA Nashville Campus…

Outcome: A thorough search of the facility was conducted with no luck locating this missing UPS Package. A station-wide e-mail was also sent, and also with no luck. Both records have been flagged as missing in the VISTA Record Tracking Package…

Issue: A physician at the VA Medical Center who is going through an investigation has on three occasions, that we know of, emailed patient information to his outside e-mail address and on at least two of these occasions forwarded these emails…

Outcome: This investigation is complete on the side of Privacy. This physician did violate VA Handbook 6500, appendix G- Rules of Behavior as well as VA Handbook 1605.1 and Facility Privacy Policy by sending these e-mails outside of the safeguards of…

Issue: Patient A picked up Patient B's medications along with his own at the pharmacy window. He contacted the pharmacy when he realized he had someone else's medications and will be returning the medications and packaging to the facility. Update: 03/20/12:Patient…

Outcome: Employees reminded to be cautious when dispensing medication packages.

Issue: A patient contacted us to report he had received two other patients' appointment letters along with his own. He is to return these letters when he has an appointment on Monday, 03/19/12. The letters contained the patients' names, addresses, partial…

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

Issue: An electrocardiogram (ECG) rhythm strip with notes on the back was found on a sidewalk outside of the VA. It had 1 patient's information on it including the full name, full SSN, date of birth, and protected health information (PHI).…

Outcome: Re-educated house staff on proper note taking and safeguarding PHI.

Issue: A VA employee, who works as an Ambassador, checked a drawer of a desk that is in the main lobby and primarily used by Ambassadors only, and found five documents which turned out to be the laboratory results of one…

Outcome: PO was unable to determine who left these laboratory reports unsecure in this desk drawer. PO worked with Service Chief of this area and all employees were educated on securing documents at all times. The Lead Clerk will always check…

Issue: An employee discovered documents containing personally identifiable information (PII) on 6 individuals in a public restroom late yesterday. As of yet, the Privacy Officer (PO) has been unable to determine who left the documents there or how long they were…

Outcome: Employee responsible reminded of the need for caution when handling documents with PII.

Issue: One of the Mental Health Program Support Assistants sent an email containing sensitive personal information (SPI) pertaining to Mental Health interns, trainees and without compensation appointments (WOCs) to incoming interns who are applying for Internship at the Memphis VAMC. The…

Outcome: This incident has been investigated with the program support staff at Mental Health Service who has implemented data handling and filing safeguards to ensure this incident does not happen again in the future. It was determined that through this incident,…