VA Southwest Health Care Network (VISN 18)

Issue: On 11/28/12, the Pharmacy Supervisor reported to the Privacy Officer (PO) that Veteran B had received three medications and accompanying educational materials for Veteran A. All three medications were non-controlled. This occurred today at the Outpatient Pharmacy window during an…

Outcome: Medications were recovered and reissued. Root cause: Staff not following high quality Pharmacy Veteran identity verification protocols. Re-education and appropriate disciplinary actions in progress. HIPAA notification letter sent to Veteran. Investigation concluded.

Issue: On 11/26/2012 a Veteran-Employee A reported that another employee B loudly disclosed his full name and full SSN twice to the Pharmacy outpatient waiting room, the afternoon of 11/21/2012. The Veteran-employee initially shared with the other employee who was dispensing…

Outcome: Pharmacy Supervisor's interview with staff did not prompt a recall of the situation described by Veteran. However, Supervisor conducted education with staff regarding Pharmacy Veteran identification protocol when dispensing medications which does not need auditory SSN in waiting area. Credit…

Issue: Patient A contacted the lab today (and the Privacy Officer (PO) subsequently talked with him) to notify us that he received a lab order for Patient B. The patient who received it is seen in Yuma. He is going to…

Outcome: We have provided additional training to staff to ensure this type of incident does not occur in the future.

Issue: One of the facility's employee/Veterans received his own appointment information last week in the mail but attached to it was another Veterans appointment information. The facility's employee/Veteran noticed it on 11/14/12, contacted and returned the document to the Privacy Officer…

Outcome: Staff members were re-educated about the importance of safeguarding patient information.

Issue: Veteran A returned a medical record that was sent to him, but it belonged to Veteran B. Update: 11/14/12:Veteran B will receive a letter offering credit protection services.…

Outcome: The Privacy Officer counseled the employee on Privacy and attention to details when processing PHI requests.

Issue: Today, 11-13-2012, Pharmacy Supervisor reports to Privacy Officer (PO) that medication and one VA correspondence intended for Veteran A was sent by mail to Veteran B. Veteran B refused the medication. He had previously received another piece of correspondence Veteran…

Outcome: Retrieval of both rx's with prompt re-issuance by Pharmacy; no interruption of service or patient care. Root cause: failure to follow Veteran identity protocols when dispensing medications. Re-education was provided to staff by Pharmacy Supervisor. Quality monitors in place. Investigation…

Issue: Veteran A reports receiving an envelope from Veteran B containing Veteran A's information. Veteran A reported this to staff in the Eligibility office and returned the papers to the Eligibility staff, stating he thought Diamond Clinic had mistakenly given his…

Outcome: Chair of clinic where breach occurred determined root cause to be inattentive handling of consult note by clerks. Corrective action to educate clerks on importance of clean desk policies already in place to prevent mixing of patient information. Credit monitoring…

Issue: Veteran A called into the front desk and said he received copies of his own records but that Veteran B's x-ray report was included with his information. The x-ray contained Veteran B's name, address, full SSN and protected health information…

Outcome: Remedial training was provided to staff to ensure incidents like this do not occur in the future.

Issue: Today, 10-31-2012, Veteran A notified PO that he had received copies of Veteran Bs medical records in the mail. He had previously requested that medical records be sent to another medical center. Instead, he received his records and those of…

Outcome: Investigation by the ROI Supervisor into the root cause determined that mis-scanning of another same named Veteran's materials into this Veteran's chart is the origin of event. This occurred in 2004. Identified staff is no longer a scanner. Supervisor provided…

Issue: A Veteran/Employee requested an inquiry into another Employee possible inapporpirate access of his record. Update: 01/31/13:Veteran/Employee A's record was looked at by another employee without proper authorization therefore, Veteran A will be sent a letter offering credit protection services.…

Outcome: Service Line notified of the inappopirate access by Supervisor/Co worker in Tele- Care. Education and training provided by privacy and sanctions suggested to SLM and HR.