VA Sunshine Healthcare Network (VISN 8)

Issue: A Patient Care Assignment/Worksheet was found on a cart that was returned to the Supply Distribution Area. This cart was on an inpatient floor from 4/13/ - 4/16/12. The worksheet contained the names, partial SSNs, admitting diagnoses and medication allergies…

Outcome: Nursing Service Management has acknowledged and responded that all Nurse Managers will be briefed with this information. They, in turn, will research the need and adapt the process of patient care assignments as deemed appropriate. Credit monitoring letters mailed 4/17/12.…

Issue: Patient A received Patient B's medication in the mail. Update: 04/16/12:Veteran B will be sent a notification letter.…

Outcome: Staff educated on proper patient identification, training provided.

Issue: Patient A received Patient B's medication Update: 04/16/12: Patient B will be sent a notification letter.…

Outcome: Staff educated on proper labeling of medications.

Issue: A bargain employee receives a 5 days suspension, but he submits a grievance to a appeal it and a quasi-judicial process is held in VA premises. One of the witnesses that was being interviewed about a fact finding she had…

Outcome: The Deputy Director reported taking appropriate disciplinary actions with the employee.

Issue: In addition to her own test results, Veteran A also received Veteran B's test results in the same envelope. Veteran A contacted Telephone triage and was instructed to mail the letter and envelope to the facility Privacy Officer for review.…

Outcome: Contractor advised Mailroom staff to fan/flip paper stack prior to inserting into sorting machine. This as a means to discharge any static buildup in the paper. Humidity tolerances within mailroom noted to be in limits.…

Issue: A VA facility called and informed the privacy Officer (PO) that they received notification from Veteran A that he received a CD with Veteran B's name, date of birth and diagnostic information on it. Update: 04/16/12:Veteran B will receive a…

Outcome: VA facility is returning the CD to the WPB PO. The Radiology Dept. has been notified and has sent a copy of the CD to the correct patient. The VA facility returned the CD to the PO. Letter offering Credit…

Issue: A Prosthetic purchasing agent was going to the Cooperative Bank around 2:45 PM, when she saw a blue folder that was left in a bank near the elevators of the basement. When she opened the blue folder she saw documents…

Outcome: The information was returned by Employee A to Employee B. Both VACHS employees and contractors were required to safeguard documents containing personal identifiable information (PII) and protected health information (PHI) as stated in Privacy Policy CM No. 00-11-15 Responsibility Clause…

Issue: A CD containing Veteran medical information was not received at its destination, which was an attorney's office. Update: 04/10/12:One Veteran will be sent a letter offering credit protection services due to full name and full SSN being exposed.…

Outcome: The program Support Assistant in the facility Radiology Department has filed a tracer ticket with UPS. They are trying to locate the CD. A letter offering credit monitoring services was mailed to the Veteran on 4/18/12.…

Issue: In addition his own test results, Veteran A also received Veteran B's test results in the same envelope. Veteran A notified the medical center about the mix-up. Veteran A will mail Veteran B's test results to the Privacy Officer, including…

Outcome: Pitney-Bowes contractor personnel verified all machine settings--no adjustments required. Humidity levels within tolerances. Contractor advised mailroom personnel to flip/fan each stack of paper prior to processing as a means to dissipate any static buildup.…

Issue: In addition to his own test results, Veteran A also received Veteran B's test results in the same envelope. Veteran A contacted telephone triage, who copied Veteran B's information and generated a Report of Contact. The nurse instructed the Veteran…

Outcome: Pitney-Bowes contractor notified. Service Chief alerted to problem. Contractor personnel verified all machine settings as correct--no adjustments required. Mailroom personnel advised by contractor personnel to flip/fan paper stacks prior to machine insertion. Humidity controls within tolerances.…