VA Southeast Network (VISN 7)

Issue: Mt. Pleasant, SC Police Department contacted our Pharmacy regarding prescription bottles being found in a dumpster. The bag was still tied and in the same condition as when it left the facility. The bag contained approximately 250 empty pill bottles…

Outcome: Pharmacy Supervisor will discuss this incident at next staff meeting. Supervisor will stress how a careless mistake can have wide spread ramifications. Supervisor will also talk one-on-one with employee who made the mistake.…

Issue: A Release of Information (ROI) Clerk inappropriately released a Veteran's medical record to the public defender's office by providing more information than requested. The documents provided contained 7332 information not authorized for release by the Veteran. The recipient of the…

Outcome: Documents returned, Veteran notified, and continuing education scheduled for ROI Staff to specifically address proper processing of request.

Issue: A Patient Service Assistant changed the address for Veteran A at 10:44 am on 9/11/12 and at 2:24 pm that same day a medication was dispensed via UPS. Veteran A called on 09/14/12 when prescription he requested had not arrived.…

Outcome: Employee was counseled on importance of changing Veteran's data and also to re-verify with Veteran before processing the change. The section has a new Chief as of Monday, 09-24-12, and Privacy Officer hopes to offer changes in the address change…

Issue: A Veteran received a letter from Benefits Travel and his SSN was exposed in the envelope's window due to the shifting of the contents in the envelope. The Veteran brought the envelope to Central Alabama HCS because he was concerned.…

Outcome: Beneficiary Travel no longer uses window envelope to mail sensitive information to Veterans. All employees made aware of the incident; Business Office leadership implemented new procedures for mailing correspondence to Veterans.…

Issue: Veteran A and his wife presented to the Dorn VA Medical Center Patient Representatives office on 09/12/12 to inform her that Veteran A had inadvertently received medical records by mail, which were intended for Veteran B. Upon research, the Chief…

Outcome: Staff has been re-educated on the need to safeguard patient information.

Issue: On 8/27/2012, the Dorn VAMC Outpatient Pharmacy inadvertently mailed Veteran A a medication package, which was intended for Veteran B. When Veteran A realized the medication did not belong to him, he immediately contacted the Dorn VAMC Pharmacy Supervisor and…

Outcome: Staff has been re-educated on the need to safeguard patient information and the importance of being vigilant when mailing medications.

Issue: On 8/27/2012, the Dorn VAMC Outpatient Pharmacy inadvertently mailed Veteran A a medication package, which was intended for Veteran B. When Veteran A realized the medication did not belong to him, he immediately contacted the Dorn VAMC Pharmacy Supervisor and…

Outcome: Staff has been re-educated on the need to safeguard patient information and the importance of being vigilant when mailing medications.

Issue: Privacy Officer (PO) received call from staff physician and researcher regarding missing files. At this point it is known that nine (9) case studies cannot be located. Facility staff are looking throughout the hospital and contacting employees not presently on…

Outcome: Although there is no proof as to what happened to the Research files, there is always speculation. Research staff have been instructed to make sure all the files are contained in a secure location, i.e. locked desk drawer and/or filing…

Issue: Veteran A received his medical records along with the records belonging to Veteran B. The records contained Veteran B's name, full SSN, date of birth and medical information. Update: 09/06/12:Veteran B will receive a letter offering credit protection services.…

Outcome: Document was retrieved and back in VA control. Further education was provided to employee and staff regarding patient privacy and safeguards. Remediation steps have been implemented and quality checks put in place to prevent such incidents from happening in the…

Issue: Veteran A received Veteran B health records. Update: 08/29/12: Due to full SSN and medical information being disclosed Veteran B will receive a letter offering credit protections services.…

Outcome: Document was retrieved by staff and back in VA control. Further education was provided to employee and department staff regarding patient privacy and safeguards. Remediation steps have been implemented and quality checks put in place to prevent such incidents from…