VA Mid South Healthcare Network (VISN 9)

Issue: Patient A received a letter from VA. Attached to the envelope was another envelope intended for Patient B. It apparently got stuck in the glue from Patient As envelope. Patient A opened Patient Bs envelope, giving him access to Patient…

Outcome: Employees reminded to be more cautious when preparing documents for mailing.

Issue: Veteran A received Veteran B's appointment letter. PHI on the letter involved full name, full address and last four of SSN. It was out of VA control for > 72 hours and Veteran A stated he shredded it after realizing…

Outcome: Re-educated employees in proper handling of PHI letters.

Issue: Veteran A requested copies of his medical record to be mailed to his residence. Upon receiving his medical records in the mail, he also noticed that he received the medical records of Veteran B. Veteran A returned the medical records…

Outcome: The PO has completed credit protection letter and it was mailed on 02/07/13. This incident has already been referred to the Business Office for appropriate action concerning the employee involved. The PO confirmed the Business Office is in consultation with…

Issue: A VA staff member found a number of files in the Mental Health Service conference room unattended. Further review of the incident by the Chief of Mental Health Service showed that one of the personnel from Joint Commission team who…

Outcome: PO spoke with the VA staff responsible for this incident and provided education on VA policies regarding appropriate safeguards to protect agency sensitive information. Staff accepted responsibility for the incident and assured PO that henceforth she will be careful when…

Issue: An Appointment letter was sent to Veteran A by an MSA in the surgery clinic. Veteran A received appointment letter and attached to the appointment letter was a consult for another patient. Veteran contacted Surgery AO to report and Veteran…

Outcome: Surgery Management alerted me to this incident as the letter was sent by surgery service. I indicated that I would place ticket and we would provide credit monitoring. Service was reminded the process of verifying information being placed in envelopes.…

Issue: Patient A received a package of medication that belonged to Patient B. When the address labels were checked, it was discovered that the mailroom had placed the wrong label on the package. Patient Aa will return the medications, paperwork and…

Outcome: Staff reminded to be more cautious when preparing documents for mailing.

Issue: Patient A was given a copy of Patient B's appointment list at his last appointment. He is to return the document to the VA today so it can verify how much information was on the list. It is unknown at…

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

Issue: Veteran A presented to the Patient Advocate that while he was a patient at the Halfway house, he was given the 12 step workbook for the program. In the back of the workbook were the names, SSN and dates of…

Outcome: The facility has agreed that all information containing a Veterans full social will be kept behind locked doors and a shredder will be utilized to shred information related to Veterans sensitive information.

Issue: Due to a staff error in an address edit, three medications were mailed to the wrong Veteran. Staff had entered a temporary address into the wrong Veteran's demographics. Two Veterans with similar last names and the same last four of…

Outcome: Our records have been corrected and the medication has been reissued to the right Veteran. The mismailed medication was returned on January 28, destroyed and associated co-pay charges were removed. The erroneous address was removed from the wrong Veteran's profile.…

Issue: A Veteran called and reported that when he was recently discharged from the VA Nashville Campus, he was provided his discharge instructions along with other documents. After he was home and reviewing these documents, he then noticed he received a…

Outcome: NOK Letter mailed on 2/5/13 and redacted copy uploaded. It was determined it was a human error that created this incident. This issue was referred to Nursing Service to follow-up with the employee involved. Nursing Service will also provide education/training…