VA Southeast Network (VISN 7)

Issue: During Telephone Advise (TAP) call on March 19, 2012 a patient reported that during a BP check at CBOC, he was given a medication reconciliation list. When he arrived home, he then noticed he had another patient_s medication list stapled…

Outcome: Department removed SSN from system for future document releases. PharmD required to retake privacy trng. Quality check of all document releases given to patients to provide two-staff verification.…

Issue: Veteran A presented to the Outpatient Pharmacy window to pick up his medication. He received all of his medication and instructions, but was also inadvertently given an Antibiotic prescription, which was intended for Veteran B. The Pharmacist discovered the error…

Outcome: Staff is being re-educated on the need to safeguard patient information and the importance of being vigilant when dispensing medication.

Issue: A Veterans wife, who is a Palmetto Health Richland RN, called the Dorn VA Medical Center Release of Information (ROI) Office to inform them that her husband received a copy of his Radiology report, and a two page list of…

Outcome: HR is working on the disciplinary action regarding the Release of Information Office employee who inadvertently mailed a spreadsheet with 17 Veterans names & ssns; She hopes to have the letter completed by Thursday for review and concurrence by the…

Issue: Veteran A called the Privacy Officer (PO) today stating the the Release of Information (ROI) section mailed records to his residence in August, 2011. Veteran A never received those records. Veteran A stated he thought the VAMC was behind and…

Outcome: Records were mailed via UPS from the facility to Veteran's home address. Veteran waits seven months to notify VAMC he never received them. UPS tracking cannot locate without the number and the VAMC does not retain numbers that far back.…

Issue: On 02/14/12, Veteran/Employee A presented to the Dorn VA Medical Center Emergency Care Department for treatment. Prior to being released from the Emergency Care Department, a Nurse provided the Veteran with verbal instructions and a copy of her discharge summary.…

Outcome: To address the human error part of this issue, the ED nursing team has embarked on a detailed re-education campaign that emphasizes proper patient identification, privacy of health information, basic attention to details and patient education at discharge. Start date:…

Issue: A Social Worker (SW) was training the staff at the Henderson Mill Annex including the Program Support Assistants (PSA) on how to read a spreadsheet so that they could make appointments according to the protocol. All staff in the meeting…

Outcome: Service training on the new appointment scheduling will be continued without the inclusion of patient information. Section leaders will be given feedback regarding the overall performance of their sections as a whole instead of discussing individual patients. Social Worker will…

Issue: On 03/01/12, Veteran A presented to the Outpatient Pharmacy window to pick up his medication. He received all of his medication and instructions, but he was also inadvertently given an antibiotic prescription which was intended for Veteran B. When Veteran…

Outcome: Staff is being re-educated on the need to safeguard patient information and the importance of being vigilant when dispensing medication.

Issue: Regional Office requested data on Veteran A from 12-15-10 to present. That information was sent to Veteran B who requested his information for personal use. When envelope arrived, spouse opened it, discarded, and put documents aside. Today the Veteran who…

Outcome: Supervisor discussed using extreme caution whenever sending requested information. This is a valued and long term employee who made a mistake and hopefully will learn from it. Employee instructed to check, double check, even triple check prior to mailing documents…

Issue: A Program Support Assistant (PSA) Clerk notified the Privacy Officer (PO) that she believes she inadvertently gave an incorrect appointment listing to the wrong patient. The incorrect patient will be notified to confirm receipt. The patient listed on appointment has…

Outcome: A notification letter was mailed on March 28, 2012 to the Veteran whose appointment listing was sent to another Veteran. The Administrative Officer of the Unit where the breach occurred will provide training at the next staff meeting to ensure…

Issue: Veteran A reported that she received a copy of Veteran B's signed discharge instructions in the mail. The one (1) page document contained Veteran B's full name, full SSN, date of birth, and appointment information. Veteran A returned the document…

Outcome: Proper procedure for handling discharge paperwork reviewed with staff. Document returned to the medical center.