VA Southwest Health Care Network (VISN 18)

Issue: Veteran A called the Privacy Officer (PO) to report the receipt of an envelope with 2 pages containing Veteran B's registration information via USPS mail delivery. He stated that he would return the entire letter, envelope and 2 pages of…

Outcome: 03/27/2012 Update: Veteran A, upon receiving Veteran B's information, immediately informed our facility Privacy Officer and then returned the two pages of original information and envelope to our facility. Responsible Supervisors conducted a fact-finding of this incident and determined that…

Issue: Veteran/Employee A states that his supervisor disclosed Protect Health Information (PHI) to his National Guard Unit Commander improperly. Update: 03/30/12:Veteran/Employee A will be sent a HIPAA notification letter.…

Outcome: Admonishment & retraining imposed.

Issue: On 02/10/12, Big Springs, TX VAMC shipped 65 boxes on two pallets to the Records Center & Vault (RC&V) in Neosho, Missouri. Yellow Freight delivered them on 02/13/12. The boxes contained medical files. Upon delivery the RC&V staff noticed there…

Outcome: Next of kin notification letters have been sent.

Issue: A Veteran provided discharge documents to A VA Provider that were not his, the Provider gave the documents to the Privacy Officer (PO). The Veteran received his correct discharge documents but upon discharge also received documents for one other Veteran.…

Outcome: Nursing supervisor has completed her investigation with ward clerk, nurse and pharmacist. Root cause identified as nurse and possibly ward clerk stapling together wrong patients' materials for discharge. The nursing supervisor counseled both the ward clerk and nurse regarding how…

Issue: A single ID label was left on an EKG machine in the hallway of our nursing home. The hallway is a high traffic area but it is unknown how many people actually saw the label. The label contain full name,…

Outcome: The label was retrieved and additional training has been provided to the employee.

Issue: Veteran A reported that he had received the lab results of Veteran B included in the appointment information mailed to his home address. Veteran A expressed concerns regarding mishandling and returned the original mailed envelope and lab results on Veteran…

Outcome: 03/16/2012 Update: Template letter and promo code for this ticket received; preparing explanation letter draft for Director's signature to be mailed to affected Veteran. Submitted: JWinstead, Privacy Officer EPVAHCS03/27/2012 Update: NSOC Ticket #71316 for closure per notification letter/credit monitoring offer…

Issue: Veteran Employee A reported that he had received the medication and medication label for Veteran B. The medication was mailed by the El Paso VAHCS Pharmacy to the address of Veteran employee A. The entire package and envelope was returned…

Outcome: 03/27/2012 Update: Responsible Supervisor for Pharmacy and Chief of Pharmacy Services documented facility fact findings regarding this issue as follows: Error occurred while Optifill was down, all Rxs were hand filled and hand checked with no bar code scanning in…

Issue: New Service Chief reports that other staff informed them of employee access to Chief's medical record. Chief requested a SPAR from PO. Based on results of SPAR, employee access is confirmed. Chief has experience in this service line and cannot…

Outcome: Supervisor indicates that the appropriate level of discipline has been administered with the employee in addition to counseling. VA NSOC will information PO of type of letter to provide to complainant; letter pending. Letter signed. Complainant notified. Discussion of situation…

Issue: A My HealtheVet Coordinator was logging in to his account to show a Veteran the steps it takes to login and when he logged into his account another patients information came up under his login. He immediately logged out and…

Outcome: ISO educated My Health Vet coordinator to no longer use his account as a teaching tool. A test patient is now used to educate Veterans on how to access My Health Vet.…

Issue: Yesterday (1-25-12) afternoon it was discovered that an Outpatient technician supervisor may have thrown a number of original controlled substance prescriptions in the trash receptacle that were likely in an previously opened UPS envelope that had been received from a…

Outcome: Aside from notifying the Veterans, we have completed remedial training with staff.