VA Midwest Health Care Network (VISN 23)

Issue: A Veteran/father received his Veteran/son's prescription and the Veteran/son received his Veteran/father's prescription. Both were receiving the same medication. Update: 06/30/11:Both Veterans will receive a notification letter.…

Outcome: Notification letter sent and the Pharmacy is updating processes and procedures to ensure a repeat is unlikely to reoccur.

Issue: Social worker disclosed patient's diagnosis and condition to local law enforcement in response to their inquiry. Inquiry was made to VA employee since Veteran had been brought in for abuse of a family member. Update: 06/30/11:The local police arrested the…

Outcome: i will be re-training all CBOC staff and the VA Police about disclosures to local police.

Issue: Son received a mental health record of his father's from Release of Information. The father and son have the same first and last name. Update: 06/30/11:The father will be sent a letter of notification.…

Outcome: Privacy Officer and HIMS Chief are working on a SOP for the release of mental health notes at the facility.

Issue: Veteran A was given a prescription to fill with Veteran B's name, last 4, and DOB on it. He returned it stating it wasn't his information. The employee was questioned and she stated she had the wrong patient pulled up…

Outcome: The employee was questioned and she stated she had the wrong patient pulled up on her screen by accident. Supervisor spoke with employee about the importance of checking patient information and completing one task before starting another patient.…

Issue: Patient A called in stating that upon discharge the nurse gave him Patient B's discharge instructions. The discharge instructions included Patient B's full name, full social security number, date of birth , instructions, and procedure information. Update: 06/14/11:Patient B will…

Outcome: Education to staff was provided. Staff was instructed to double check the patient when giving instructions.…

Issue: A Human Resource HR Technician sent an internal VistA e-mail message to the wrong mail group. The message contained the full name, Date of Birth (DoB) and full SSN of a new employee. The group it was sent to contains…

Outcome: The HR Techs will now create a message that contains the limited and non-sensitive information to send to the large group of recipients and then will add the sensitive information to the second message which is sent to the four…

Issue: Veteran A received Veteran B's lab letter in the mail. Update: 06/09/11:Veteran B will receive a letter of notification due to the disclosure of the lab results.…

Outcome: Put QA process in place to check envelopes coming out of mail machine.

Issue: Veteran A contacted a pharmacy employee to report that he received Veteran B's refill slip in the package he had received in the mail from the pharmacy. The refill slip contained Veteran B's name, address and medication information. The pharmacy…

Outcome: A notification letter has been sent to the Veteran and the pharmacy employee was counseled on the importance of accurately handling refill slips.

Issue: The Information Security Officers (ISO) were looking through the Sensitive Patient Access Report and came across an employee accessing a family member's chart. The ISO gave the report to the Privacy Officer (PO). The PO will follow up with the…

Outcome: Education was given to employee.

Issue: A patient label with a full name, full SSN, and Date of Birth (DOB) was found in a public hallway. Update: 05/10/11:Patient B will be sent a letter offering credit protection services due to full name, full SSN, and full…

Outcome: Unable to determine how it got into hallway. Credit Monitoring letter sent.