Veterans In Partnership (VISN 11)

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

Outcome: Information was retrieved and staff were educated. Notification letter was mailed to patient today.…

Issue: Veteran A called to state he had received Veteran B's prescription information consisting of one drug information sheet and renewal information for three other medications. Veteran A stated he would send the information back to the VA to the attention…

Outcome: Notification letters have been mailed, Pharmacy service educated employees on error and process to prevent mis-mailed documents.

Issue: A Social Work Service employee has inappropriately accessed the record of their spouse. The Veteran stated to another VA employee that their spouse knew things about his care (urine screens) and other information that she should not have access to.…

Outcome: Administrative Investigation Board has been formed. CPRS access has been removed pending outcome of AIB. Disciplinary action has been recommended by the PO/ISO with findings turned over as evidence to the board. Notification letter has been sent, redacted copy uploaded…

Issue: One prescribed medication vial for Veteran A was placed in the prescription bag of Veteran B (along with Veteran B's other prescription vials). Veteran B took the bag of prescription vials (his and Veteran A's) home with him, prior to…

Outcome: The pharmacy staff are being re-educated to double check all prescriptions prior to putting them into the medication bags for Veterans.

Issue: Veteran A was inadvertently given Veteran B's medication upon discharge from VA Illiana Health Care System. Update: 03/22/12:Veteran B will be sent a notification letter.…

Outcome: Education reminder given to Nursing staff to ensure they double check before they give out medication to patients being discharged. HIPAA notification letter sent to Veteran.…

Issue: During a visit to the emergency department, Patient A received an armband with personally identifiable information of Patient B Update: 03/13/12:Patient B will be sent a letter offering credit protection services due to full name and full SSN being exposed.…

Outcome: Staff has received additional training by supervisor for use and placement of armbands.

Issue: A VA Provider sent a response through My HealtheVet Secure Messaging to the wrong patient. The communication consisted of the patient's last name only and discussion of the patient's feet and ankle issues. Update: 03/09/12:One Veteran will be sent a…

Outcome: The My HealtheVet Coordinator reminded the provider of his responsibility for patient confidentiality and the importance of maintaining the Veteran's trust in the MHV Secure messaging system. The MHV Coordinator also called the patient that received the wrong information and…

Issue: Veteran/Patient A returned a Patient Payment History Report that was mailed to him and belonged to Patient B. The report includes Patient B's full name and full SSN. Update: 03/06/12:Patient B will be sent a letter offering credit protection services…

Outcome: Credit monitoring letter mailed March 12, 2012. CPAC supervisor notified of mis-mailing. PO will provide a follow-up Privacy Training for CPAC staff.…

Issue: Veteran complaint alleging inappropriate access to Veteran Medical Record after receiving a copy of her sensitive patient access report. Update: 03/27/12:Veteran A will be sent a letter offering credit protection services.…

Outcome: Privacy Report has been sent to respective service chiefs recommending education and disciplinary action for inappropriate access to the Veterans Medical records. Credti Monitoring offer and complaint response letter have been sent to the Veteran.…

Issue: Veteran A and Veteran B both had outpatient procedures the same day. Veteran A was handed discharge instructions with Veteran Bs full name, full social security number, and birth date. Update: 02/29/12:Veteran B will be sent a letter offering credit…

Outcome: The Privacy Officer conducted (at the request of the nurse manager) an in-service with the same day surgery staff involved in this incident. All staff understood the importance of proper documentation.…