VA New England Healthcare System (VISN 1)

Issue: A prescription was prepared and now the patient is calling for it. No one knows where the prescription is. It could have been mailed to the wrong place or it could have been stolen. Update: 12/06/12:A Veteran will be sent…

Outcome: Pharmacy is getting 3 new cameras installed on will be in the vault. The process has been changed and education has been given to the employees to eliminate this from happening again in the future.…

Issue: A doctor asked the Privacy Officer (POP) to investigate a call he had received from a person at the check cashing dept of the Hannafords Grocery Store Corporate Office. The person stated he had received a prescription faxed to their…

Outcome: HIPAA letter completed and attached, Education provided.

Issue: Veteran A's Coumadin progress note was mismailed to Veteran B. Update: 12/06/12:Due to full SSN and medical information being exposed, Veteran A will be sent a letter offering credit protection services.…

Outcome: The clerks who mail these letters have set a system up in which they ensure that they seperate all letters and validate with a count of the number of letters printed.

Issue: Employee found a wheelchair in hallway outside of their office. There was a sticker on the wheelchair with a Veteran's PII. The Privacy Officer (PO) is not at the facility where the event occurred; the ISO on site is investigating.…

Outcome: PO sent notification letter to Veteran. Investigation is ongoing to determine the point of origin of the breach. If a responsible Service or employee is found there will be re-training and a change in process. Thus far, this appears to…

Issue: Patient A received a prescription for oxycodone for Patient B. It was discovered when Patient B came to get his medication and the signature log showed that it was picked up by Patient A. The prescription was returned to the…

Outcome: Pharmacy is putting processes into place to avoid this in the future.

Issue: A nurse picked up the two patient medications but gave them to the wrong Veterans. Veteran A went home with the bag of eye drops and was called later to return them which his wife did later the evening. The…

Outcome: Employee educated on the importance of double checking for patient safety and privacy.

Issue: A volunteer employee admitted to an employee that the volunteer accessed the file of the employee and asked the employee if the employee would be working on their birthday. The employee asked how the volunteer employee knew the birthday. The…

Outcome: Volunteer Employee terminated.

Issue: Employee left a folder containing PHI/PII in an unsecure area. Privacy Officer (PO) investigating and awaiting more detailed information. Update: 11/13/12:One Veteran will be sent a letter offering credit protection services due to full name and full SSN being exposed.…

Outcome: The employee responsible has been counseled by their supervisor and is assigned to re-complete VA Privacy and Security Awareness Training. The employee is not authorized to remove any documents from the area unless the documents are in a secure tote.…

Issue: Patient communication letter regarding Veteran A from a physician including full name, address, SSN, Date of Birth and medical information regarding thyroid ultrasound results were sent to Veteran B. The veteran who received this information mailed the letter back. The…

Outcome: Credit monitoring letter sent to veteran. Education provided to service line.…

Issue: The Providence VA Medical Center (PVAMC) sends Dermatology patients to a local hospital for surgery appointments, that hospital sends the results back to the VA Dermatology department. Yesterday, a resident physician was instructed to bring the packet of patient information…

Outcome: Derm changed the way they are transporting the MOHS packets, this will provide for better security.