VA Southwest Health Care Network (VISN 18)

Issue: During the course of a privacy complaint investigation, an access report confirmed that an employee accessed another employee's medical record. Update: 02/08/13:Due to unauthorized access of full SSN and medical information, Employee B will be sent a letter offering credit…

Outcome: This was an incidental find and was reported to the Service Chief of the employee involved. This is being investigated and the employee will be subject to disciplinary action. Employees are required to take Privacy training every year.

Issue: An Administrative Assistant notified the Privacy Officer that a Chief contacted him of 2 mis-directed Veteran letters. Veteran A notified the Chief that she received a letter intended regarding Veteran B for a senator's office. Upon notification to the Administrative…

Outcome: Determined that the usual mailing label quality check was not performed. Busy environment and multi-tasking contributed to 2 envelope labeling mis-application. This has been remedied by changing the time of mailing label application, and review of mail contents prior to…

Issue: A veteran received appointment letters for another veteran. The letters contained the name, address, and SSN. The veteran who received the letters returned them to the clinic that mailed them. Update: 02/08/13:One Veteran will be sent a letter offering credit…

Outcome: Staff received supplemental education.

Issue: On Monday, 2/4/2013, it was reported to the Privacy Officer (PO) by a Human Resource Specialist that he had mislaid employee documents. This had initially occurred when e-QIP documents for two physicians were faxed to him. On January 2, 2013,…

Outcome: HR Technician was able to retrieve one set of documents but additional documents are outstanding. HR Chief provided and PO provided additional education regarding tracking and security of sensitive paper documents. Alternative document distribution cycle related to EQIP is in…

Issue: Today, 1/30/13, the Pharmacy Supervisor reports that Veteran B returned 2 prescriptions to the Pharmacy which were intended for Veteran A. Veteran B was the ED last evening when he was dispensed an antibiotic and a steroid. At home, Veteran…

Outcome: After hours processing has been adapted in the handoff from Pharmacy to the ED patients. Medical record documentation has also been reviewed and corrected by HIMS Chief. Staff involved were provided with additional pharmacy identification.

Issue: Veteran A was handed a packet containing information for Veteran B. The packet contained the name, full SSN, the spouses name, address, telephone numbers, other personal information, and a list of medications. Veteran A was looking at it later and…

Outcome: Additional training was provided to staff to avoid incidents like this in the future.

Issue: On 1/28/2013, The Pharmacy Supervisor reported to the Privacy Officer (PO) that Veteran B received antibiotics meant for Veteran A at the outpatient pharmacy window on 1/25/2013. This was discovered by the pharmacy technician who could not find medications for…

Outcome: Medications and rx education materials were recovered by Pharmacy. A change in workload, reassignment and re-education was performed by the Pharmacy supervisor regarding Veteran identity when dispensing medications. Pharmacy Chief is also working on another automatic Veteran identity matching program…

Issue: X-ray film containing patient name & full SSN was found near facility dumpsters laying on furniture prepared for disposal. Update: 04/08/13:The patient will receive a letter offering credit protection services.…

Outcome: Unable to determine responsible person. It is likely that this was left by the patient.

Issue: Veteran A picked up a bag of medication at a CBOC location. The Veteran left with the bag but later realized that the bag was for Veteran B with the same last name. Veteran A took the bag to the…

Outcome: Additional training was provided to staff to avoid incidents like this in the future.

Issue: On 1/15/2013 the Privacy Officer (PO) contacted Veteran by phone after Patient Advocate reported Veteran complaint. Veteran reports that after his appointment on Friday morning, 1/11/2013, he was called back to the front desk to arrange for his physician to…

Outcome: Nurse Manager called Veteran to address clinical or any other concerns. Nurse manager will be implementing staff training regarding new customer service skills and ensuring that Veteran has access to his team to address his concerns. Nurse manager documented phone…