VA Sunshine Healthcare Network (VISN 8)

Issue: Instructor demonstrated during CPRS orientation for new employees what he thought was bogus patient information. One of the new employees recognized the last name as a current employee and brought it to her attention. When confronted, the instructor insisted the…

Outcome: NEO computer training will now use a hard copy handout only for training Time and Leave actions and the EMPLOYEE MENU. Neither the live VistA account nor VistA TEST account will be used for NEO training of the EMPLOYEE MENU…

Issue: A number of checks and explanations of benefits for Fee payments were mismailed to an individual. The individual reported the issue and returned the checks without the original envelopes to Health Resource Center (HRC). HRC in turn advised our facility.…

Outcome: Finance has updated the station standard operating procedure guide on Vendorizing submissions to incorporate address screening and to follow the Finance Service Center requests to properly vendorize. Staff members will be taking the following courses in TMS; VHA Privacy and…

Issue: A Bay Pines employee recently passed away at the facility. An audit log revealed that more than one employee had inappropriately accessed the deceased employee's electronic record. Update: 05/16/12:The Veteran's next of kin will be sent a notification letter.…

Outcome: The employees who inappropriately accessed the medical record of the deceased individual have all received some form of disciplinary action from their supervisors. They have been informed by the Privacy Office that patient privacy and confidentiality is taken very seriously…

Issue: Patient A received a prescription for patient B in the mail. Update: 05/17/12:Patient B will be sent a letter of notification.…

Outcome: Education provided to staff. Processes and procedures evaluated and process improvements made to avoid error.…

Issue: A VA employee accessed another VA employee's electronic medical record . Update: 05/16/12:The employee did admit to entering the other employees record to print a list of appointments. The employee states they were asked to do so, however the other…

Outcome: Additional training and education was provided to the employee on the importance of not accessing records that are not on a need to know basis during there daily duties. The supervisor was notified for further action.

Issue: Veteran A received an appointment reminder letter. Attached was a list of future appointments for the same clinic including the full names and full SSNs of 9 other Veterans. Update: 05/15/12:A letter offering credit protection services will be sent to…

Outcome: New processes have been put in place to safeguard patient information (handling/mailing). Employees and Volunteers have been provided additional training related to protecting patient information.…

Issue: Veteran A received Veteran B lab results. PO contacted Vet A who is returning lab results to PO. Update: 06/04/12:Veteran B will be sent a letter of notification.…

Outcome: UTD where mishandling occurred. PO spoke with all staff who could have been directly involved. Most likely a mail machine malfunction in the 'envelope stuffing' process.…

Issue: Veteran A received an appointment reminder letter. Attached was a list of future appointments for the same clinic including the full name and full SSN of sixteen (16) other Veterans. Update: 05/10/12:A letter offering credit protection services will be sent…

Outcome: Health Administrative Services and Voluntary Service will continue to monitor this process. A volunteer was responsible for the mis-mailing the document that was prepared/printed by an HAS clerk. The information will be thoroughly reviewed prior to disclosing or mailing. All…

Issue: An employee included a Patient's name and diagnosis (who is also an employee) on an employee recognition form. The submitter listed the Employee/Patient's last name and medical condition while to trying to recognize a fellow employee for a job well…

Outcome: Employee who wrote the nomination cards has been cautioned by supervisor to exercise more care when writing nomination cards and to avoid references to patients' medical condition. We believe this was a momentary lapse and will not happen again.…

Issue: Veteran A received notification letter belonging to Veteran B. Update: 05/07/12:Veteran B will be sent a letter offering credit protection services. Veteran B's full SSN was disclosed.…

Outcome: Document misdelivered by USPS.