VA Southwest Health Care Network (VISN 18)

Issue: Veteran A reported and provided to facility Privacy Officer that he had received information on another Veteran "B" - which had been included with appointment notification letter mailed to his home address. He provided the original incorrectly mailed information to…

Outcome: 06/22/2012: Review of incident with responsible Interim Nurse Manager and Supervisor, Centralized Records Unit-Release of Information area revealed that CBOC was responsible for inappropriate inclusion of information on incorrect Veteran which was included in mailing of information to another Veteran.…

Issue: Veteran A informed the facility that while he was in the lab, Veteran B overheard a lab tech asking for Veteran A's name, SSN, and DOB. Veteran B used that information to steal Veteran A's identity. Veteran B was arrested…

Outcome: We have supplied staff with additional education to ensure this does not occur in the future.

Issue: Report of contact received stating that Veteran/Patient mail was received opened from another service. This is the second time this type of event has been provided to Privacy Office. Update: 06/05/12:The Veteran/Patient will be sent a notification letter.…

Outcome: Unable to determine person responsible for this, so general education provided to the service,

Issue: On 06/05/12, the Pharmacy Supervisor reported to the Privacy Officer (PO) that Veteran B received a controlled medication that was intended for Veteran A by mail. Upon notification, the Pharmacy determined that the controlled medications for both Veterans were mailed…

Outcome: Staff failure to follow identification protocol was addressed with re-education regarding Pharmacy dispensing protocols. This was also addressed with appropriate disciplinary actions.…

Issue: Today, Pharmacy Supervisor reported that Veteran Bs wife picked up Veteran As medication at the Pharmacy window. Veteran Bs medication was received in addition to the controlled medication for Veteran A: morphine 30 mg and 60 mg. Both Veterans had…

Outcome: Root cause: Failure to follow Veteran identity protocol for medication dispensing. Repeat issue. Report of contact in progress by employee. Additional notification and investigation to ensue.Appropriate HR disciplinary actions in progress. Education with employee regarding Privacy consequence.

Issue: Pharmacy Supervisor reports that Veteran B received medication by mail intended for Veteran A. Prepaid envelope to recover Medication provided to Veteran B. Pharmacy processed medications again and dispensed to both Veterans. Review of addressing indicates that another department changed…

Outcome: Supervisor provided with documentation that their employee made address change. Investigation determines that a same named person was seen at the employee's clinic that day. The employee failed to verify part or full SSN so the other same-named person was…

Issue: On 05/30/12 at 9:30 AM, Patient A received medications for Patient B at the PVAHCS Outpatient Pharmacy Out-window. Patient A was contacted about the error and informed that his medication(s) would be sent via UPS and a return envelope will…

Outcome: Pharmacy supervisor was able to identify the root cause as human error. No process issues involved. She provided immediate education to the staff member regarding high quality patient identity matching protocols to be followed. Letter to Veteran.

Issue: A VA staff member was seen accessing a patient's record while here on his day off. The record accessed is reportedly that of a patient no longer on the staff member's unit. The staff member was seen printing from the…

Outcome: In addition to notifying the Veteran, additional training has been provided to staff, and the staff member involved has received disciplinary action.

Issue: Veteran had received copies of his medical records and 2 pages were of another Veteran. Update: 05/24/12:One Veteran will be sent a letter offering credit protection services due to full name and SSN being disclosed.…

Outcome: ROI clerks were reminded to check information taken from the printer to assure all pages are of the correct Veteran,…

Issue: A VA employee did not secure/safeguard a cardex at the end of the work day on 05/17/12. When the employee came to work on 05/18/12, the cardex could not be located. This cardex contained names, last four digits of the…

Outcome: Supervisor re-educated employee on safeguarding PHI.