VA Sunshine Healthcare Network (VISN 8)

Issue: Veteran B's medication was mailed to Veteran A. Veteran B's date of birth and SSN were not disclosed. Update: 03/19/12: Veteran B will be sent a notification letter.…

Outcome: Education provided to staff on the proper method of identifying patient's for pharmacy.

Issue: A VA doctor mistakenly gave a patient todays appointment schedule. The appointment schedule has a total of 16 patients listed including the patient that was given the appointment list. The facility contacted the patient and the patient agreed to return…

Outcome: Appointment List was returned to VA and destroyed as it was no longer needed. The clinic is developing a process to minimize use of appointment lists and to ensure the security of those that are used. Employee involved completed re-training…

Issue: Respiratory Technician called Veteran A and left name and appointment information on Veteran B's phone voice mail. The Employee called Veteran A again and left correct information. Update: 03/16/12:Veteran A will receive a notification letter due to have his medical…

Outcome: PO reviewed with employee the correct 'minimum necessary' information that is to be left on a voice message. Requested Clinic Chief discuss same with all staff at next staff meeting.

Issue: VA provider gave a copy of Veteran A's lab results to Veteran B during appointment. Veteran B discovered he had the wrong information before leaving the facility reported the event and returned the documents to the Release of Information department.…

Outcome: Training was provided to the employee on the importance of making sure information is checked before giving to the Veterans.

Issue: Veteran A received a copy of his authorization for Fee Services in the mail. Attached was Veteran B's authorization for services as well. Veteran A reported the event to the Port Charlotte Community Based Outpatient Clinic (CBOC) in person and…

Outcome: Supervisor notified and Privacy training was given to the employees by the Privacy officer.…

Issue: A patient received billing information from his recent fee basis provider. However, the envelope arrived with a torn address window, and was originally addressed to the VAMC's billing department. Visible through the torn envelope was the Veteran's full SSN and…

Outcome: Credit monitoring letters offered to affected Veterans. Torn envelope attributed to USPS.…

Issue: Veteran A presented to a Community Based Outpatient Clinic (CBOC) appointment and informed the staff that he received a letter for Veteran B in error. The letter contained Veteran B's name, address and protected health information (PHI) Update: 03/19/12:Veteran B…

Outcome: Information was returned to the Privacy Officer. Community Based Outpatient Clinic (CBOC) staff have been reminded of appropriate handling procedures when preparing documents for mail.

Issue: A Veteran returned two separate lab results (for different Veterans) to a Health Administration Services (HAS) clerk indicating that had been mailed to his residence and sent in the same envelope as his own lab work. The HAS clerk failed…

Outcome: Emphasizing to all employees the need to double-check envelope contents with addressee before mailing. Notification Letters sent to affected Veterans.

Issue: Veteran A arrived at a contracted nursing home with Veteran B's medical records to include discharge summary and instructions and medication list. The business associate reported the incident to Bay Pines VA and returned the records. Update: 03/09/12:Veteran B will…

Outcome: Credit Monitor letter was mailed to one Veteran. Employee(s) responsible for providing information to the contracted nursing homes when Veterans are transferred were all further educated on taking additional safeguards when handling PHI/PII. Supervisors were also asked to further educate…

Issue: A contractor's compliance officer informed by letter that their employee had recently stored an unencrypted file on a tablet in order to schedule patient appointments. According to her letter, the file included the following categories of information about 34 Veterans:…

Outcome: Companies contract ends by the end of this month and will not be renewed. Contractor took action against staff that caused this incident.