Veterans In Partnership (VISN 11)

Issue: A pharmacy employee placed an eye drop medication for Veteran A in a bag of medications intended for Veteran B. Veteran B discovered the error when they were home and opened the bag. Veteran B contacted the Pharmacy and reported…

Outcome: Employees involved in this incident have been educated on the proper review process to follow regarding medication dispensing quality checks. Notification letters have been sent to the Veteran whose information was compromised.…

Issue: Veteran A picked up 2 prescriptions at the pharmacy window. The prescriptions were for Veteran B. The envelope with the prescriptions had Veteran B's full name, full address, birth date and ticket number. Each of the prescription s had the…

Outcome: Per the supervisor in pharmacy, there was no way to determine what employee handed the medications to the wrong Veteran. Supervisor re-educated all staff.…

Issue: A multi-dose medication vial and box were misplaced (dropped) in a parking lot in Kalamazoo, MI. On the box was a medication label that contained one Veteran's name and medication strength. Update: 10/13/11:One patient will be sent a letter of…

Outcome: Employee responsible for this incident has received formal counseling and has been retrained regarding local policies for transporting and safeguarding PHI and medication, a locked bag has been issued to the employee and more for the service.

Issue: A nursing assignment sheet was found unattended in the atrium of building 200. The sheet contains the names, DNR status, and care instructions for eleven (11) Veterans. Update: 10/12/11:Eleven Veterans will be sent a letter of notification.…

Outcome: Employee has been counseled by PO and supervisor. PO recommended to Unit and service an inventory process be put in place at shift change to ensure all assignment sheets are turned in at the end of every tour. Notification Letters…

Issue: Information was mailed to Veteran A and Veteran A states there was information about Veteran B in the packet of information. The Privacy Officer (PO) is trying to contact Veteran A to obtain more information. Update: 10/17/11:Awaiting update from the…

Outcome: The supervisor will have the employee retake his privacy training, double check all pages before mailing or handing to a Veteran, and request a printer due to the high volume in the one printer.

Issue: An excel spreadsheet was discovered to be missing by a Physical Therapy Assistant at the outpatient clinic. The employee states he had it one minute, provided treatment to a Veteran and the sheet was gone. A thorough search did not…

Outcome: The employee has been counseled, and the clinic is not going to print or use the VISTA appointment list anymore. Credit Monitoring letters have been sent to 23 impacted Veterans. VISTA appointment list will no longer be printed or used…

Issue: A Pharmacy technician inappropriately mailed Veteran A's Refill slip with "no refills remaining" to Veteran B in error. The slip for Veteran A was stuck behind the slip for Veteran B. Update: 09/27/11:Veteran A will be sent a notification letter.…

Outcome: Pharmacy employee has been educated to ensure the refill slips are separated prior to mailing back to Veteran.

Issue: A Registered Nurse discovered a nasal culture in a bio-hazard bag lying on the ground in a parking lot location. Update: 09/27/11:The culture contained the patient's first and last name, full SSN, and was found unattended in the parking lot.…

Outcome: Nurse received verbal counseling. Matter can be closed.

Issue: A clerk handed a beneficiary travel form for Patient A to Patient B. Five minutes later Patient B brought it back to the clerk. Update: 09/20/11:Patient A will be sent a letter offering credit protection services due to full name…

Outcome: Credit monitoring letter has gone out. Staff have been educated. Supervisor was notified of incident.…

Issue: Release of Information (ROI) clerk sent medical information to a county office. The release form (10-5345) did not authorize the information that was sent. The information was sent on 09/08/11. The Clinical Psychologist found out on 09/12/11 that the wrong…

Outcome: The employee has taken additional training to include review of policies and procedures. A random sampling of his work is reviewed prior to mailing.…