VA Southwest Health Care Network (VISN 18)

Issue: US Postal Service delivered a mangled/broken package back to the El Paso VA HCS Mail Room containing copy of Veteran medical record and noting "Found Loose in the Mail"; "We're sorry that your package was damaged during processing" and "Atlanta…

Outcome: Mitigation and Corrective Action overview: Noted that Medical Records Unit sent the package certified mail via USPS and spoke with the work studies previously to ensure that the documents were secure, and that there was secure packaging clear tape on…

Issue: Veteran A returned information to the Supervisor for the Primary Care Clinic which had been mistakenly enclosed with an appointment reminder and sent to his home address. (Veteran had already thrown away the envelope in which this information had been…

Outcome: This mismailing resulting in the privacy breach of 4 Veterans has been reviewed with nursing staff as well s clerical support staff and medical staff. Corrective action included re-training and heightened awareness of all responsible staff, emphasis upon privacy of…

Issue: Veteran A received a fax cover sheet in the mail that contained Veteran B's first and last name, address, date of birth and full SSN. Update: 04/24/12:Veteran B will be sent a letter offering credit protection services.…

Outcome: Data was secured and Veteran offered credit monitoring. The process changed and staff re-educated.…

Issue: On 04/19/12, a Pharmacy supervisor reported that Veteran B received medication in the mail for Veteran A. UPS returned the medications to the pharmacy today for proper disposition. Additional event information pending. Further notification and investigation to ensue. Update: 04/19/12:Veteran…

Outcome: Medications were returned and had reissued correctly. Root cause of rx provided was identified as Pharmacy employee error. Both Veterans involved had same last name except for one alpha character. Failure to follow identification protocols. Re-education regarding identity verification and…

Issue: Veteran A provided copies of medical records on Veteran B which had been mixed into the printing and disclosure provided to Veteran A. Veteran A stated that he had requested and received his copies of his medical record from the…

Outcome: 06/19/2012 Update - Verified completion of corrective action per responsible supervisor; not yet completed so reminder sent for immediate resolution and follow-up. Submitted: Privacy Officer EPVAHCS 06/28/2012: Corrective action completed and resolution forwarded to facility Privacy Officer. PSETS ticket updated…

Issue: A VA Supervisor inappropriately accessed the electronic health record (EHR) of a Veteran employee. Update: 04/19/12:Veteran/Employee A will be sent a notification letter.…

Outcome: Verbal counseling and retraining was provided by the supervisor.

Issue: Veteran A reported to the facility Privacy Officer that he received pharmacy insert information included with his mailed prescription to his home address. The pharmacy insert included in Veteran A's packet included prescription information and included the full name of…

Outcome: Update per Chief, Pharmacy as follows: 04/19/2012: Findings: Fact finding and review of incident determined that - Veteran A received his Rx in the mail for drug X which was checked by Staff RPh #6. The person that prepared the…

Issue: Veteran presented to facility Privacy Officer with opened/torn UPS box which had been sent from facility Medical Record Section approximately a week and a half ago to home address of Veteran. Upon receiving the UPS box, Veteran noted that it…

Outcome: 05/23/2012 Update: Fact finding completed by involved facility staff (Privacy officer, FSS Chief and mail Room Lead staff, medical Records/Release of Information Supervisor; and contract/account Representative for UPS courier service. Determination that packet of medical record was searched for at…

Issue: A Veteran Employee passed away January 24, 2012. Sensative Patient Access Report was run by Assistant Director of chart. The report indicates potential unauthorized access by a staff member. Review of other staff access was also reviewed. Their appropriate access…

Outcome: During the fact finding, the employee indicated that they had accessed VISTA as indicated. This issue became disciplinary at that time in conjunction with re-education on job-appropriate access. Employee disciplinary actions are confirmed by Chief to be in progress with…

Issue: Today, 04/11/12, the Pharmacy Supervisor reports that Veteran A received a prescription package for Veteran B. This was discovered by Veteran A who returned the materials to the Pharmacy. The Supervisor's initial investigation shows that Veteran B's address was incorrectly…

Outcome: Although Supervisor counseled employee regarding the address entry error that triggered this event, the root cause was human error. Encouraged supervisor to address and observe root cause issues to implement a fix or system change. Supervisor does not believe that…