VA Southwest Health Care Network (VISN 18)

Issue: Last night the Education Department (ED) faxed information to a number that used to belong to a particular nursing facility. (The nursing facility had not updated a list for their own people to use and they gave the wrong number…

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

Issue: Today, 7/31/2012, Pharmacy Supervisor reports that Veteran B received Veteran As Prescription (Rx) in the mail by UPS. Rx was refrigerated, non-controlled. Veteran B contacted the Pharmacy to report on 7/31/2012. Arrangements in progress to recover Veteran As Rx and…

Outcome: Supervisor is following appropriate course of disciplinary action. Education with staff provided by Supervisor re appropriate Veteran identity matching protocols for medication dispensing.

Issue: On 07/27/12, Veteran A from the Abilene Community Based Outpatient Clininc (CBOC) dropped off 2 packages that were delivered to his house with his address on the package and the Veteran B's name sent from VHA 18 Pharmacy (WTVAHCS). Out…

Outcome: Health Administration Services staff corrected the Veterans name and addresses . Pharmacy was also contacted to verify and correct medication distribution. Veterans have been contacted for verification and update of record information and notification of mix up.…

Issue: A label containing 1 Veteran's name, full SSN, and DOB was left in the front tray of an EKG machine in an unsecure area. Update: 07/24/12:The Veteran will be sent a letter offering credit protection services due to full name…

Outcome: Additional training was provided to staff as to prevent similar incidents in the future.

Issue: An EKG label for one patient was left in the front tray of an EKG machine on a patient ward. The EKG machine was not in a secure area. A lab supervisor was doing an internal inspection and found the…

Outcome: Additional training was provided to staff as to prevent similar incidents in the future.

Issue: Information was mailed to Veteran A via certified mail. It was never received. It is undetermined who has received it, if anyone. The envelope has not been returned to the VA. The Patient is upset about not receiving documents. Update:…

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

Issue: A volunteer lost a blood sample while transporting it from the blood draw area down to the lab. The lab sample label had the patients name, full SSN, and test information on it. An exhaustive search is still being conducted.…

Outcome: The patient was notified by Risk Management, Patient Safety, and the lab rescheduled to come in and provide a new specimen. We have also changed the process of transporting specimens to the testing lab.…

Issue: It was reported this morning that an employee at the NW CBOC spoke to someone on the phone who identified themselves as a family member of a Veteran. The employee reviewed a providers note and told the family member that…

Outcome: The staff in this area has been retrained on the proper procedures for discussing patient information with others without proper authorization from the patient.

Issue: On 06/29/12, a Social Worker at a Community Based Outpatient Clinic reported to the Privacy Officer that 12 pages of a Veteran\xe2\x80\x99s medical record was faxed to a residential address in Texas instead of intended non-VHA agency. The Social Worker…

Outcome: Social Worker assisted the other agency's incorrect fax number both on their website and on their fax cover pages. Followup thank you letter to faxed recipients with request for materials back after a phone call by PO. Local fax contact…

Issue: A timekeeper's list of employees' full names and full SSNs was found on a ward printer. The printer was located in an unsecured area. The list was discovered on the morning of 06/25/12 but was printed out either Saturday 06/23/12…

Outcome: We have implemented additional training for admin staff to ensure this issue does not occur in the future.