VA Southwest Health Care Network (VISN 18)

Issue: An EKG printout was found on an EKG machine on the nursing home ward. The printout contains the patients full name , DOB, and last 4 of the SSN. There is only one patient involved. Update: 08/28/12:The Patient will be…

Outcome: Employees in that section have been retrained to ensure future incidents do not occur.

Issue: A social worker at the Sierra Vista Community Based Outpatient Clinic (CBOC) inadvertently handed a Veteran the wrong appointment sheet. The Veteran didnt notice it for a couple of weeks and brought it back to the CBOC. This affected 1…

Outcome: Additional training was provided to staff to ensure future incidents do not occur.

Issue: On 8/23/2012 the Outpatient Pharmacy Supervisor notified Privacy Officer (PO) that a woman impersonated a Veterans mother. Earlier today, she picked up Veterans prescription for Bactrim, an antibiotic. She provided the Veterans name, street address, and DOB. It is not…

Outcome: Pharmacy employee has been re-trained about how to check two separate patient identifiers at prescription pick-up by Pharmacy Supervisor. The training has been completed and random monitoring has shown correct procedure for medication pick-up.

Issue: Veteran A's lab results were mailed to him and in the same envelope was Veterans B's lab report containing his lab results, address, full name and full social security number. Update: 08/22/12:Veteran B will receive a letter offering credit protection…

Outcome: Staff was educated to be more aware of what was being sent out to Veterans. Also the name and social security numbers have now been removed from the letters by the CAC.…

Issue: An employee found an EKG printout for one Veteran on the floor in the canteen during lunch time. It was secured and returned to the Privacy Officer (PO) . Update: 08/22/12:Veteran A will be sent a letter offering credit protection…

Outcome: Staff has received additional training so that future incidents do not occur.

Issue: An employee on the third floor noticed that the bulletin board near the elevator had a patient ID label stuck on it. Update: 08/20/12:The patient will be offered credit protection services as the label contained the full SSN.…

Outcome: Unable to determine cause of event or person responsible.

Issue: A Veteran reports that claim information to State Farm Insurance was sent to the wrong mailing address. Update: 08/16/12:The Veteran will be sent a letter offering credit protection services, as his full SSN was disclosed..…

Outcome: Privacy Officer counseled person responsible for this event on attention to details and awareness of where information is being sent in order to protect patient privacy.

Issue: Today, 8/15/2012, the VA Police reported to the Privacy Officer (PO) that printed Veteran materials are visible in a car located in the physician parking area of the facility parking lot. They traced the car to a physician but could…

Outcome: Physician was counseled by his Compliance manager in his practice. Disciplinary review and actions are pending by Service Chief. Signed letters of Credit monitor offers sent to Veterans today.

Issue: A package of information was picked up by veteran A. Information for veteran B was included in the package. Veteran A returned the document to the clinic within one hour. Update: 08/10/12:Veteran B will be sent a letter offering credit…

Outcome: Additional training has been provided to staff to ensure other incidences like this do not occur in the future.

Issue: A Veteran contacted the VA to report that he received a letter from this facility notifying him that he has colon cancer. The envelope was not sealed shut; the flap was merely tucked into the envelope. This affected one Veteran.…

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