VA Southeast Network (VISN 7)

Issue: Veteran A presented to the Outpatient Pharmacy Window to retrieve his prescribed medication. It was determined that Veteran B had inadvertently received Veteran As medication earlier the same day. The window pharmacy technician retrieved the incorrect Veterans medication from the…

Outcome: The Privacy Officer has generated and mailed the Notification Letter to the Veterans. Re-education was provided to the VA employee regarding appropriate methods for handling and securing patient sensitive information. The Privacy Officer's investigation is complete and is requesting that…

Issue: Patient A was discharged from the Birmingham VA Medical Center (BVAMC) on Sunday, August 26, 2012. When Patient A opened the brown bag of medication at his home, it contained 5 medications and discharge paperwork for he AND Patient B.…

Outcome: All medications were returned to BVAMC Pharmacy. Employee was counseled and trained regarding Privacy issues.…

Issue: Patient A presented to the Birmingham VA Medical Center (BVAMC) Community Based Outpatient Clinic (CBOC) in Guntersville for a 10:00 appointment on the employee. Upon review of the appointment listing, the employee discovered that Patient A had been given the…

Outcome: Employee was counseled and required to complete Privacy training module in TMS. Document was retrieved.…

Issue: A Pharmacy Technician sent a package containing a controlled substance via UPS to a Veteran. The package was sent to an old address that had not been deleted from the UPS address book. The mail room has placed a "Return…

Outcome: Pharmacy supervisor is in the process of trying to obtain ScriptPro contract which would have our Veteran's address download to UPS shipping label. The address is erased after label is printed. This would prevent wrong meds going to wrong location.…

Issue: A Veteran called to report that he received a package in the mail from the medical center that contained appointment reminder letters for 9 Veterans. The letters contained the Veteran' name, the last four digits of the SSN, mailing address,…

Outcome: Documents returned to the Privacy Officer. Appointment reminder letter are being transitioned into reminder post cards with less PHI data elements.

Issue: A male Veteran approached the volunteer desk in the atrium and handed her a carbon ribbon that contained 220 patient names (full name, date of birth, and full SS#). Some of these names are possible duplicates. Though the ribbon contained…

Outcome: Credit monitoring letters mailed 9/11/2012. BVAMC Police consulted with the Inspector General (IG) who advised no further action required. Environmental Management Service (EMS) contacted contractor to discuss the issue. No fault determined to be on the employee.

Issue: A VA Pharmacy employee inappropriately disclosed a Veteran's name, address, diagnosis and sex offender status to a non-VA employee. Counseling has been provided by the immediate supervisor. The Privacy Officer (PO) has recommended that VA employee re-take the Privacy/HIPAA training.…

Outcome: The Privacy Officer has generated and mailed the Notification Letter to the patient. Re-education has been provided to the staff regarding appropriate measures to protect and secure all patients' sensitive information. The OGC guidance on Sex Offenders was disseminated to…

Issue: The VA Pharmacy Service staff reported that Veteran A received medications and an instruction sheet on Veteran B. Both patients receive the same blood pressure medication with the same directions. Veteran A found the error and held the prescription along…

Outcome: Pharmacist responsible for mishandling/mis-mailing error was counselled by Pharmacy Svc. supervisor (per e-mail on 8/14/12).

Issue: Veteran reported that his appointment letters were sent to the wrong address. The individual who received the Veteran's information in the mail returned the documents to him in the mail, with a note indicating what had occurred. The Veteran then…

Outcome: Documents recovered and returned to medical center Privacy Officer. Clinic appointment letters are being transitioned to postcard reminders with less descriptive details.

Issue: Patient A presented to the Huntsville Community Based Outpatient Clinic (CBOC) with paperwork addressed to Patient A that he received in the mail from the Birmingham VA Medical Center (BVAMC) which contained a Release of Information form with Patient B's…

Outcome: Document was retrieved. Employee was required to complete Privacy training course and counseled.…