VA Mid South Healthcare Network (VISN 9)

Issue: Family member of Veteran A reported that Memphis VAMC mailed information to her father-in-law via his home address and when the information was received, it contained Veteran B's records. She stated that when she read through the record, she saw…

Outcome: Credit monitoring letter has been mailed out to the affected Veteran. This case is considered closed as of 10/4/2011. PO drew Release of Information Staff attention to this incident. All the staff were present and were advised to pay close…

Issue: Patient A picked up medications, discovered Patient. B's package included with his own. Returned the package to the pharmacy before leaving the facility. Update: 07/28/11:Patient B will be sent a letter of notification.…

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

Issue: Veteran A's wife stated two years ago she received an application for benefits from Memphis VAMC. The form contained someone else's name and SSN and the name and SSN of the person's spouse. The complainant called the Medical Center regarding…

Outcome: Credit monitoring letter has been mailed and redacted copy has been uploaded. PO met and discussed this incident with Mail Room Supervisor to monitor the mailing process to identify the problem. The Supervisor explained that the mailing flow is an…

Issue: Patient A contacted the pharmacy call center in Murfreesboro, TN and reported he received a medication belonging to Patient B at his temporary address in Southport, NC. Upon investigation, a pharmacy administrator learned Patient A had given his temporary address…

Outcome: 7/28/11 - During a clinic visit, Patient A requested the clerk change his address in the computer. The clerk was working in Patient A 's and Patient B's record, simultaneously, and inadvertently entered the address change into Patient A's record.…

Issue: On 07/20/11, Veteran A was scheduled an appointment in Radiology (Nashville campus) for a chest x-ray. While waiting to be called for the x-ray, Veteran A reported to the Patient Advocate Office to request assistance with an issue. The Patient…

Outcome: 8/8/11 - Radiology employees involved did not follow standard protocol for placement of an armband. Appropriate disciplinary action taken (Employees were given letters of reprimand which were also included in their six-part folder). CM letter mailed today.…

Issue: An employee who has filed a grievance against her Chief used medical records for evidence in her case. She took copies of medical records to the Union office to keep as evidence for her case. During one of the meetings,…

Outcome: This case is completed. I have found that the MSA inappropriately disclosed information on the patient to employees who did not have a need to know in order to support her grievance case. I have provided a summary to HR…

Issue: An employee found an unused patient label lying on the floor in the hallway. It is unknown how this label was left in the hallway. It is also unknown when it happened. The label contained the patient's name and full…

Outcome: Unable to determine who was responsible.

Issue: Veteran received another veteran's medications by mail. Veterans had same last name. Update: 08/10/11:Veteran B will be sent a notification letter.…

Outcome: Post Office delivered to wrong address. VA safeguarded appropriately.…

Issue: On 07/11/11, Patient A presented to Pharmacy (Nashville campus) and reported that he received medications which belonged to Patient B. Patient A signed for these medications at the post office and, upon returning home, discovered they belonged to Patient B.…

Outcome: Pharmacy found the medications were mailed out from the Consolidated Medication Outpatient Pharmacy (CMOP) and not TVHS. Pharmacy reported the incident to CMOP and re-mailed Patient B's medications to him. HIPAA Notification letter mailed to Patient B.…

Issue: Patient A received a prescription for Patient B. The pharmacy discovered the error and notified the physician responsible for providing the prescription. The physician mistakenly entered the wrong patients chart and documented the encounter and wrote a prescription. The physician…

Outcome: Re-educated employee on importance of paying attention to detail.