VA Southwest Health Care Network (VISN 18)

Issue: On 01/24/12, a VA physician informed the Privacy Officer (PO) that Veteran A received a completed form for Veteran B in the mail. The physician had previously mailed completed forms to both Veterans. The physician is now calling Veteran B…

Outcome: Documents recovered by physician and PO. Physician has counseled both parties with immediate appropriate credit protections. PO has done same for Veteran A. Physician has developed a new outgoing mail protocol which will be a double check that ensure mail…

Issue: Several medication bottles came loose during a UPS shipment. The bottles were scuffed up but the labels were readable. The patients names, medication name, and last four digits of the SSN were on the bottles. This affected 2 Veterans. Update:…

Outcome: We have spoken to the contractor and staff about ensuring prescriptions are secured in packaging when transported. Packaging has been modified and made stronger to lessen the occurance of this type of problem.…

Issue: An electrocardiogram (EKG) printout was left on the podium in a conference room. It was brought to the Privacy Officer (PO) by a staff member. This printout contains the patients full name and SSN and DOB, and a potential diagnosis.…

Outcome: We spoke with personnel who left the printout in the conference room and provided additional training on safeguarding patient information.

Issue: The Acting Nurse Manager for Ambulatory Surgery reported the loss of a packet that included one patient chart. Initial efforts at attempts to find the chart have been unsuccessful. The loss was reported to the Patient Safety Officer and Privacy…

Outcome: 03/19/2012 Letter offering credit monitoring and notification to Veteran whose record was lost provided to Director's Officer for signature and mail-out to affected Veteran. Redacted letter for uploading to NSOC; recommend ticket closure based on above documentation of fact-finding, remediation/corrective…

Issue: The supervisor took a printout home to contact Veterans. This list contained the names, addresses, phone numbers, and the last 4 of the SSN. The supervisor let his teenage son assist in calling the Veterans which meant the son saw…

Outcome: Aside from notifying the Veterans, we have updated our training awareness policy and conducted training in that area.

Issue: A supervisor suspected that one of her employees was going into her co-workers medical records and requested the Privacy Officer (PO) to check out the access records for these employees. An employees name appeared on several of the access reports.…

Outcome: All employees requested and were provided with a copy of their access report for review. The employee who accessed the records received disciplinary action. All of the staff received remedial training.…

Issue: USPS returned two medications that came loose in the mail to the Tucson CMOP. They were scuffed but the labels were still intact. It is unknown where they were and for how long. It is unknown who saw them after…

Outcome: We have provided retraining for staff regarding the proper way to ship patient information in a more secure manner.

Issue: Yesterday the supervisor in Beneficiary Travel noticed a box of reproduction materials that was set for distribution to Veterans regarding the Electronic Funds Transfer (EFT) program. He didnt recognize the information and began reviewing it. In the packet was an…

Outcome: We have provided staff with additional training and have added a new quality process so supervisors must check all new informational packages being given to veterans beforehand.

Issue: A VA Pharmacy Supervisor reported to the Alternate Privacy Officer (PO) that Veteran A picked up a medication intended for Veteran B on 12/16/2011. Veteran A did receive their own medications and did not consume Veteran B's medications. Veteran A…

Outcome: ROC written by staff indicates root cause analysis, correction of process, and future preventative measures. Pharmacy supervisor reinforced corrective measures with other staff.

Issue: Pharmacy Supervisor reports that Veteran A reports receiving a bottle of medication/education sheets for Veteran B in the mail. This was one of three package was addressed to Veteran A. However, there was one prescription and educational material for Veteran…

Outcome: Employee provided with counseling regarding event. Chief indicates that root cause is a known FMEA issue. Purchase request has been entered into the equipment package to address root cause issues. Service Chief also indicates that quality measures have been reinforced…