VA Southwest Health Care Network (VISN 18)

Issue: Today, 1/14/2013, Pharmacy reports to PO that supplies intended for Veteran A were received in the mail by Veteran B. Veteran B contacted facility; he received his own supplies as well. Upon report, recovery efforts for the Veterans supplies (lubricating…

Outcome: Rx and materials were recovered by Pharmacy. Root cause: Failure to follow Veteran identity protocol. Re-education with staff involved by Pharmacy Supervisor regarding Veteran identity protocols in the Pharmacy prior to dispensing meds was reemphasized. New shift assignments in this…

Issue: On 01/11/13 the Privacy Officer (PO) was notified by Pharmacy that Veteran B was provided three medications meant for Veteran A at discharge on 11/9/2012. Veteran A notified the Pharmacy of this occurrence on 1/10/2012. Medications were recovered from Veteran…

Outcome: Staff was re-educated immediately. Pharmacy is changing staffing in the dispensing area and workload in response to this even. HIPAA notification letter drafted for Director to review, signed, mailed and sent 1/17/2013.

Issue: A Veteran called and reported a message was left on his answering machine from a VA employee which included his diagnosis. Update: 01/10/13:The Veteran statedhe played the message while his son was in the room. He also had a friend…

Outcome: The Service Line was notified and the employee will be re-trained . The Veteran was mailed notification letter

Issue: A Veteran was admitted today and was given Veteran B's ID bracelet. Ward staff noticed it and notified the appropriate parties. Update: 01/09/13:Veteran B will be sent a letter offering credit protection services, as his full SSN was disclosed..…

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

Issue: Veteran A, who receives home health care, had medication information on Veteran B mixed in with his own medication print outs from the Pharmacy. It was discovered by the home health caregiver who returned the information to the VA. Veteran…

Outcome: Notified by pharmacist that person responsible could not be determined, but that training and awareness will be offered at next staff meeting.

Issue: The Driver's License of Veteran A was mistakenly handed back to Veteran B by a Volunteer handling Wheelchairs at the front greeting desk. Veteran B noticed the error and returned the incorrect Driver's License of Veteran A. Then Volunteer noted…

Outcome: Update to ticket per fact-finding: Clarification noted that Volunteer Service Assistant (not a Volunteer) drove to Veteran B's house and returned his license with the intention of retrieving Veteran A's license. Veteran B was unable to find Veteran Veteran A's…

Issue: A cancellation of appointment letter was sent out to Veteran A about her mental health appointment and Veteran B's cancellation letter was also sent to Veteran A by mistake. Veteran A immediately called the VA and informed the VA of…

Outcome: A letter was sent to the Veteran notifying him of the mis mailing. The PO also called the Veteran and explained what has happened. Spoke with Chief of the service that mails out letters and they will educate their employees…

Issue: A staff nurse viewed the medical records of two coworkers. This was discovered through an audit of the sensitive record access log. Update: 12/03/12:Employee A and B will be sent a notification letter.…

Outcome: We have provided additional training to our staff so that future incidents will not occur.

Issue: A letter was written to a staff members ex - wife which was addressed from his fiance that is also an employee at this facility. The staff member has a concern with individuals accessing his record that do not have…

Outcome: Processes are being changed to prevent this.The employee that accessed her fiances records has had her access revoked until further notice, and the other two employees that accessed their Chief's record without a need to know have been couseled and…

Issue: Veteran A received a letter containing information on Veteran B in the mail. The information was first and last name, last four of SSN and medical diagnosis. The data was secured. Update: 12/03/12:Veteran B will receive a HIPAA letter of…

Outcome: The department was notified . Education and training provided. The Veteran was notified of the disclosure.…