VA Southwest Health Care Network (VISN 18)

Issue: Today, 03/21/13, the Nurse Manager of Home Care reported a missing Veteran roster of the contract Community Based Nursing Home Veterans. A nurse who works in the community printed a paper list of approximately 75 Veterans for her community encounters…

Outcome: Nurse manager was provided with additional references and verbal guidance regarding allowing staff to take PHI off campus Both nurses involved were provided with re-education regarding transportation of hard copies of materials with supervisory approval. The supervisory written approval for…

Issue: A Social worker faxed PHI to a wrong number. Update: 03/19/13: The Veteran will be sent a letter offering credit protection services.…

Outcome: Supervisor has counseled employee and HIPAA training is current.

Issue: Veteran A was given Veteran B's discharge orders and future appointments along with Veteran A's information upon discharge. Update: 03/13/13:Veteran B will receive a letter offering credit protection services.…

Outcome: Staff was provided additional training to ensure incident like this do not occur in the future.

Issue: Today, 3/11/2013, pharmacy Supervisor reported that Veteran B received an injectable drug for Veteran A by mail in addition to his own medication. Veteran A's first name, last name, drug, physician, and address on bottle were exposed. The medication was…

Outcome: The root cause of failure to follow Rx bagging and Veteran identity matching protocols in the Pharmacy was identified. A new SOP has been developed for ID matching with employee in-service. Additional one-on-one education in the Pharmacy was conducted. Veteran…

Issue: Today, 3/4/2013, PO returns Veteran phone message. Veteran indicates he received a follow-up appointment response letter from his PCP with instructions for his next appointment. Underneath his materials, were the same types of letters for 12 other Veterans. The Veteran…

Outcome: The provider could not identify who in her PACT actually sent the letters to multiple Veterans in one envelope. She then conducted an in-service and one-on-one counseling session with all of her staff, showing them the Privacy Officer memo on…

Issue: A package was received by Risk Management via priority mail from Veteran A. The contents were copies of Veteran B's CPRS notes and other sensitive agency information that the Veteran was not authorized to have in his possession. There was…

Outcome: A criminal investigation is ongoing to determine person(s) responsible for this event.

Issue: On, 02/28/13, the Pharmacy Supervisor reports that Veteran B received a mailed medication for Veteran A in addition to his prescription. Neither prescription was a controlled substance. The package was labeled for Veteran B which contained both Veterans prescriptions. Upon…

Outcome: The root cause of failure to follow Rx bagging and Veteran identity matching protocols in the Pharmacy was identified. A new SOP has been developed for ID matching with employee in-service. Additional one-on-one education in the Pharmacy was conducted. Veteran…

Issue: Veteran A received a copy of Veteran B's medical records in the mail. Veteran A returned them to the local Community Based Outpatient Clinic (CBOC). The records contained Veteran B's name, address, full SSN, date of birth and protected health…

Outcome: We have provided additional training for staff to ensure incidents like this do not occur in the future.

Issue: Outpatient pharmacy supervisor reports Veteran A returned medications to a distant CBOC today. Veteran A reported that upon discharge last night, nurses gave him his own discharge medications as well as the discharge medications of Veteran B. When Veteran A…

Outcome: Root causes were determined to be similarity of patient names and SSN; changing discharge plan of Veteran B caused his discharge medications to be placed on the ward, although by the time of discharge Veteran A was to be the…

Issue: Veteran A received Veteran B's appointment sheet upon discharge. Update: 02/14/13:Due to full SSN and medical information being exposed, Veteran B will be sent a letter offering credit protection services.…

Outcome: We have provided additional training to employee to ensure this does not occur in the future.