VA Southwest Health Care Network (VISN 18)

Issue: An envelope of hard-copy prescriptions was being transported from the NW Community Based Outpatient Clinic (CBOC) to the main facility via UPS. The envelop never arrived and it contained prescriptions for 12 patients. Each prescription contained the patients name, address,…

Outcome: We have trained staff to begin using larger, padded envelopes for sending prescriptions so they are less likely to fall behind seats or catch on the conveyor belts and catch fire in the future.

Issue: Today, 12/08/2011, the Pharmacy Supervisor reported to the PO that 2 medications were mailed in error to a Veteran. The Veteran called the Helpline to inquire about medication mailing status of 2 ordered medications. At that time, the address error…

Outcome: Investigation conducted with VACO Privacy Officer indicates that they now also have the correct address. No audit trail in their software to determine who sent us this address. No further information available to identify the error. However, provided the VACO…

Issue: On 12/08/11, the Privacy Officer (PO) was notified by Pharmacy that Veteran A picked up Veteran B's prescription. The medications were the same but the quantity for Veteran B was higher than for Veteran A. Prescription educational materials were accurately…

Outcome: Root cause identified both technician and pharmacy protocols not followed. Pharmacy supervisor reviewed and counseled staff regarding privacy and patient safety impact.

Issue: Veteran A requested a copy of his medical record and the record received were not his. Update: 11/17/11:One Veteran will be sent a letter offering credit protection services.…

Outcome: Supervisor was notified and training and counseling will be provided to employee.

Issue: On 11/14/11, the Pharmacy discovered that a UPS package containing 11 Schedule Class II hardcopy prescriptions was not delivered at South Arizona VA Health Care System (SAVAHCS). The package was picked up on 11/08/11 at the Northwest (NW) VA Community…

Outcome: We have notified the patients and are working with the contractor to create a new process that will reduce the risk of losing a package in the future.

Issue: A Pharmacy Supervisor reports a Privacy Incident in which Veteran A received a controlled substance prescription and prescription education materials intended for Veteran B from the Pharmacy. The Error was discovered when Veteran B reported to the Pharmacy dispensing window…

Outcome: Retrieval of medications achieved by Supervisor's actions with Veteran cooperation. Veteran destroyed other documents received in error. Counseling and re-education regarding dispensing protocols performed by Pharmacy supervisor. Report of Contact written by staff received by PO.

Issue: Today, 11/14/11, a Nurse Manager reported to the Privacy Officer (PO) that he observed clinical staff scanning what appeared to be a paper bar coded document while dispensing medications on Thursday, 11/10/11. After identifying this apparent work-around for the bar…

Outcome: Appropriate disciplinary measures are being addressed by Nurse Manager and HR. Additional education to this unit provided by Nursing management regarding appropropriate use of medication bar codes. Further monitoring in place by Nurse Manager. Nursing Administration plans to have all…

Issue: A VA Nurse Manager reported to the Privacy Officer (PO) that he received a letter on 11/07/11 from Veteran B, a former patient subsequent to disciplinary action regarding a current employee. Veteran B indicated that his letter was in defense…

Outcome: On the basis of the privacy breach, made disciplinary suggestions to supervisor and HR based on the HR Table of Penalties. Appropriate disciplinary actions pending. HIPAA Notification Letter provided to Veteran Patient.…

Issue: Late yesterday afternoon , Veteran A attempted to pickup 2 medications from the Pharmacy. One prescription had previously been dispensed. Upon Pharmacy review, it was discovered that this medication was dispensed yesterday to a same surnamed patient. An internal investigation…

Outcome: Pharmacy supervisor audited medication dispensing for both Veterans. Dispensing tech has had a prior similar event. Supervisor requested and provided a Report of Contact to employee. Disciplinary actions pending. Similar occurrence for the same Pharmacy Tech per supervisor indicates that…

Issue: Release of Information clerk faxed Provider's medical information including full SSN to a fee based cardiology clinic instead of the Veteran's information. Update: 11/08/11:The Provider will be offered credit protection services since his SSN and medical information was disclosed inappropriately.…

Outcome: Service Line manager notified . ROI clerk given a verbal counsel and re-training .…