VA Sunshine Healthcare Network (VISN 8)

Issue: Patient A received a prescription inhaler intended for Patient B and used it. Update: NA…

Outcome: Facility has commenced an RCA. QM has advised staff on the respective floor of their responsibility. Notification letter has been mailed to patient.

Issue: The research compliance officer conducted an audit of a research protocol and found that a signed HIPAA authorization was not in the study file for one patient. The patient submitted a letter to the facility indicating that he remembered signing…

Outcome: CM Letter was mailed to subject. He also signed a new HIPAA authorization.

Issue: A VA employee provided Veteran A with Veteran B's discharge instruction sheet. The discharge instruction sheet contained the full name and procedure of Veteran B. The VA employee recognized the error and contacted Veteran A who confirmed he had received…

Outcome: The staff member received administrative action; re-educated about patient safety and our verification policy for Veterans including checking patients' armband, asking the patient to state his/her name in full, and social security number in full; repeated Privacy and HIPAA training…

Issue: VA employee mis-faxed a Veteran's medication list and note. The information faxed contained the Veterans full name, date of birth and full SSN. Privacy will investigate. Update: 02/19/13:This was sent to a private home. The fax number was mis-dialed by…

Outcome: The employee who incurred the mistake has re-taken VA Privacy and Information Security Awareness and Rules of Behavior training, as well as VHA Privacy and HIPAA training. Credit monitoring letter sent to the affected Veteran and redacted copy uploaded.…

Issue: Veteran A was mailed Veteran B's medical records. Update: 02/07/13:Veteran B will be sent a letter offering credit protection services due to full name and SSN being disclosed.…

Outcome: Supervisor notification to o have employee(s) at a minimum re-take Privacy and ISO training and to contact HRMS for appropriate disciplinary actions.…

Issue: Release of Information mailed lab and radiology notes to Veteran A which should have gone to Veteran B. Update: 02/04/13:Veteran B will be sent a letter offering credit protection services, as his full SSN was disclosed…

Outcome: I/R/S completed. Verbal counseling and QA process review.

Issue: Veteran A received Veteran B's appointment letter and medications. Update: 02/04/13:Veteran B will be sent a notification letter.…

Outcome: UTD who was at fault however Service Supervisor and Section Supervisor advised to educate.

Issue: Veteran A reported that he received the lab results of Veteran B in the mail. Update: 02/05/13:Veteran B will be sent a letter offering credit protection services, as his full SSN and lab results were disclosed..…

Outcome: Veteran A returned the information to the facility. The PO has mailed a copy of the lab results to Veteran B. Medical Administration Supervisor has been informed and has reviewed the process with the appropriate staff to prevent reoccurrence.LETTER OFFERING…

Issue: Veteran/Employee A was mis-mailed Veteran B's medical appointment information. The appointment letter includes Veteran B's full name, mailing address, and appointment information (date/time/clinic). Update: 02/01/13:Veteran B will receive a HIPAA letter of notification.…

Outcome: VA employee involved retook VA Privacy and Information Security and Rules of Behavior and VHA Privacy and HIPAA training. Service reminded all clerical staff of the importance of mailing the correct information to the correct Veteran.HIPAA Notification letter mailed to…

Issue: Veteran A presented to local community-based outpatient clinic (CBOC) and stated that approx. one month ago while at the main clinic, he was given Veteran B's appointment list by mistake, which he didn't discover until he went for what he…

Outcome: Event will be briefed at next staff meeting to enhance clerks overall awareness.