VA Southeast Network (VISN 7)

Issue: Veteran A's mother called the Dorn VA Medical Center Release of Information Office (ROI) to inform them that her son received a two page disability form by mail, which was intended for another Veteran. The two page disability form was…

Outcome: Staff is being re-educated on the need to safeguard patient information.

Issue: Veteran A received a list of four Surgery Clinic appointments during his Primary Care (blue team) visit on 04/11/12. The Veteran was surprised to see that he was inadvertently given an appointment list, which was intended for Veteran B. Veteran…

Outcome: The Dorn VAMC Chief of HIM (Alternate Privacy Officer) provided facility wide training on the need to safeguard patient information.…

Issue: Pharmacy staff were in the vault filling prescription requests (controlled substances) when they placed two different Veterans' requests in one bag. Video review showed Veteran A being given Veteran B's prescription. Veteran A was contacted and confirmed he had the…

Outcome: Vault staff has reviewed their procedure for filling and checking prescriptions and has made changes to prevent this from happening in the future.

Issue: The Privacy Officer (PO) was notified by Patient A that he received appointment letters for two other patients at his address. The PO requested that Patient A provide copies of the appointment letters he received. Patient A will bring copies…

Outcome: PO discussed the situation with the chief mailroom clerk, who then had the mail sorting machine calibrated in efforts to prevent this from reoccurring. Notification letters sent to patients. Redacted copies of said letters are attached.…

Issue: A Veteran complained stated that a VA employee had accessed his/her electronic medical record. Update: 05/11/12:Alternate PO is conducting investigation. She has received issue brief and some statements. Investigation continues.05/24/12:Complaint change to an incident, Employee A looked at Veteran's B…

Outcome: Employee counseled on proper procedures of patient privacy.Employee provided with further educationService may request an action to HR in the futureCorrective actions have been put in place to prevent future incidents

Issue: On Tuesday, 04/10/12 the Privacy Officer (PO) was contacted by the PO at an affiliate medical center regarding a stolen personal laptop. A former Chief Resident, who is now an Attending, reported that on 03/30/12, his personal laptop was stolen…

Outcome: Process for residents, trainees, etc. clearing is being addressed by the Chief of Staff and the Education department. Policy in development.…

Issue: Veteran A received Veteran B's controlled medications. Veteran A is blind and took some of the tablets. Veterans A and B are related (cousins). Veteran A had his brother take the medications to Veteran B's home. Veteran B will be…

Outcome: Supervisor in Pharmacy spoke with the Vault staff and reminded them to double check the UPS addresses against the Vista Label addresses. Supervisor is also working with our pharmacy automation company to develop a better way to print the UPS…

Issue: On 3/30/12, a nurse practitioner (NP) reported that an appointment schedule list (print date 3/20/2012) containing the name of two veterans was missing from her desk. The schedule contained the veterans' full name, SSN, appointment information, service connection, and phone…

Outcome: The Privacy Officer (PO) has recommended that the employee read and acknowledge the receipt of the "Clean Desk Policy" and the local Privacy Policy regarding Reasonable Safeguards attachment A, page 8. Upon completion, have the employee to sign and date…

Issue: On 3/28/2012, Veteran A received a reminder by mail of an upcoming Spartanburg Primary Care Clinic appointment. The Veteran was surprised to see a second appointment letter, which was intended for another Veteran included in the same envelope. Veteran A…

Outcome: Staff is being re-educated on the need to safeguard patient information.

Issue: The CMOP mailed medication to two different Veterans that were returned to the hospital's pharmacy due to bad addresses. The Pharmacy Technician called the Veterans to obtain their correct addresses. When medications were sent back out, they were both placed…

Outcome: Supervisor spoke with employee regarding importance of assuring medications are sent to the correct address and the right Veteran.