VA Mid South Healthcare Network (VISN 9)

Issue: Supervisor entered and reviewed treatment (date/time) of subordinate that is a Veteran/Employee. Verified that supervisor entered employees record 1 time. Investigation is continuing. Update: 11/17/11:The employee will be sent a letter of notification.…

Outcome: Administrative Action was taken, as well as repeat of privacy training.

Issue: Patient A received Patient B's lab letter. The protected health information (PHI) included Patient B's full name, address and lab results. The Privacy Officer (PO) was able to recover the letter but it was outside of VA control for greater…

Outcome: PO states re-education was provided for all staff of the service. We were unable to determine who mailed it.…

Issue: Patient A notified the pharmacy that they had received Patient B's prescription along with their own through the mail. They are sending the prescription and the packaging back to the pharmacy. Update: 10/24/11:Patient B will be sent a notification letter,…

Outcome: Staff reminded to use more caution when packaging medications for shipment.

Issue: Pharmacy dispensed fifty-six morphine tablets intended for Patient A to Patient B. Patient B realized he had the wrong drugs and notified the pharmacy, he was instructed to bring the tablets with him. He came to the pharmacy and picked…

Outcome: We requested the prescription be returned from the wrong patient. We have educated the staff to insure two identifiers are validated to the correct patient, so he is receiving the designated prescription.…

Issue: On 10/19/11, while an employee/Veteran A was an inpatient, a Nurse at the ACY Campus, who is assigned to a different Ward than the one the employee/Veteran A was admitted too, was observed by another Nurse accessing employee/Veteran A's CPRS…

Outcome: Nursing Service is working with HR for the appropriate level of disciplinary action against the Nurse involved with this case, which will also include re-education concerning accessing of CPRS records. CM Letter to be mailed to Veteran this date.

Issue: Patient A contacted the Pharmacy to report they had received Patient B's medication along with their own. Patient A will return the medication and paperwork so the facility can determine who was responsible for the error. At this time, the…

Outcome: Staff reminded to be more cautious when packaging medications for shipment.

Issue: Veteran A received a copy of Veteran B's information during a request of Release of Information (ROI) of his own information. Veteran A will return Veteran B's information personally today to the ROI office to HIMS Chief. Veteran A indicated…

Outcome: Supervisor spoke to employee regarding the records being sent to the wrong Veteran. The supervisor also had a meeting with the rest of the staff to discuss the importance of reviewing everything that is being sent out before placing in…

Issue: Patient A was given Patient B's medication list. Patient A lives at the local Veterans Home. He turned the document in to the staff at the Home when he arrived there. Update: 10/17/11:Patient B will be sent a letter offering…

Outcome: Unable to identify specific individual responsible. Staff reminded of the need for caution when handling documents with PII.…

Issue: Last week, Veteran A contacted the Business Office (Murfreesboro Campus) to request an enrollment packet be mailed to him. Veteran A is not currently enrolled in TVHS.Yesterday, October 13, 2011, Veteran A received the enrollment packet in the mail and…

Outcome: 11/7/11 - Incident caused by human error. No specific employee identified. Business office staff has been reminded of the importance of checking documents for accuracy before mailing. Enrollment packet was returned to Business Office.…

Issue: Employee found a file beside the drive to the hospital. When he opened it, he discovered documents with PII/PHI. Although the ISO has not been able to examine each document yet, it contains the last names & last fours of…

Outcome: Resident reminded that no PII is to be removed from the facility; that it must be disposed of properly.