Veterans In Partnership (VISN 11)

Issue: A wrist band for Patient A was improperly placed on Patient B. Patient A's name and full SSN were compromised. Update: 06/15/12:Patient A will receive a letter offering credit protection services.…

Outcome: The wrist band procedure has been more clearly defined with the responsibility of who places the wristband now with the clerical staff. The employee who made the error has been educated. Credit monitoring letters have been sent to the impacted…

Issue: Veteran A received a letter from the FEE Basis department that should have been sent to Veteran B. Both Veterans have the same first and last names and the same middle initial but not the same middle name. The Veterans…

Outcome: Supervisor will talke with employee involved and also conduct training for the entire service.

Issue: An appointment list containing two names was visible on a clinic clerk's desk at a VA Illiana Health Care System (VAIHCS) Community Based Outpatient Clinic (CBOC). The list contained the patients' names, full SSN , data of birth and home…

Outcome: The employee will be given updated training on the Clean Desk Policy and a counseling.

Issue: A Veteran received a single-sided appointment card with full name address and last 4 on the front of the card and appointment date/time and required lab test prior to appointment displayed on the back. Update: 06/13/12:Veteran B will be sent…

Outcome: Staff at the Community Based Outpatient Clinic (CBOC) have been informed to discontinue use of and destroy and remaining of these unauthorized post cards immediately and under no circumstances to include any personally identifiable information /protected health information (PII/PIHI) on…

Issue: During the course of transporting an inpatient Veteran to a court hearing, a nursing escort employee inappropriately delivered a patient escort slip, CPRS cover sheet, problem list, and active medication listing to the Calhoun County Probate Court. the information at…

Outcome: Appropriate staff have been educated regarding the safeguarding of records containing III and PHI as well as only providing the minimum necessary to those with sufficient authority and a valid need to know. Credit Monitoring letter has been sent to…

Issue: A lab technician found a doctor's order for mammography that had been faxed from a non VA health care facility on the table outside her office where patients sign in for laboratory testing. The order contained the patient's name, date…

Outcome: Education was provided to the lab technician.

Issue: A social worker obtained an authorization from a patient to disclose his information to a non VA health care provider for the purpose of admission for detox, and disclosed several progress notes to the non VA health care provider. The…

Outcome: Counseling and education was given.

Issue: At the conclusion of an appointment on 05/25/12 at 8:15 AM with Veteran A at the Grand Rapids Pharmacy Anticoagulation Clinic, a staff clinical pharmacist mistakenly gave Veteran A a 2-page appointment list, including the names of 13 Veterans, their…

Outcome: Credit monitoring letters have been sent to 13 Veterans impacted by this event. Provider has been educated on the importance of safeguarding paper copies that contain PHI.…

Issue: An employee at VA Illiana Health Care System in Danville reported that she had taken test result reports of three different Veterans to a copy machine in her area to make copies in an attempt to provide a better quality…

Outcome: HR will work with the service on a disciplinary action. Also, the process to be reviewed and further training provided to service.…

Issue: A prescription mailed to Veteran A inadvertently included a prescription vial for Veteran B; the vial label included the Veteran B's name, the prescription number and name of medication, directions and indication it was to be used for pain or…

Outcome: Prescription verification and packaging process has been improved, employees involved have been trained and a notification letter has been sent to the Veteran.