Veterans In Partnership (VISN 11)

Issue: On the second day of an Information Technology Oversight and Compliance (ITOC) inspection, the ITOC inspector requested to see the hard copy, wet signature Rules of Behavior (ROB) forms on 5 employee/contractors to see if the documentation was on file.…

Outcome: New security measures have been implemented for the remaining documents and a more secure mechanism for maintaining these records in the future has been put in place.

Issue: Veteran A received an appointment letter intended for Veteran B. The letter included appointment information and Veteran B's full name. Update: 06/13/11:Veteran B will be sent a notification letter.…

Outcome: The PO sent an email to all areas that send out appointment letters to have them remind staff to double check letters going out to Veterans. The PO could not pinpoint where this specific letter was sent from.…

Issue: Veteran A received lab results on Veteran B. Update: 06/21/11: The report contained Veteran B's full name, full social security number, birth date. age and one lab result. Veteran B will receive a letter offering credit protection services.…

Outcome: The employee has retaken both Privacy and Security training. She will be subject to periodic ongoing work checks to ensure accuracy. She has received disciplinary action. She will review the contracted CBOC's standards of Performance.…

Issue: The Infection Control Officer sent a letter to the county health department with the Veteran's son who is the next of kin (NOK) listed as the infected individual in error. The letter contained the NOK's name, date of birth and…

Outcome: Infection Control Officer has reviewed letter generation process and understands the mistake that was made. Local Health department has been contacted in an attempt to gain access to the state reporting system in order to make the letter process no…

Issue: Veteran A called saying he received an envelope with Veteran B's information. He could not tell the Privacy Officer exactly what the information was, although he did not see a social security number. Veteran A is sending the information to…

Outcome: The supervisor educated the employee about patient confidentiality, being detailed orientated, and double checking that the correct information is stuffed into the correct envelope. The employee has been instructed to re-take the privacy training in TMS.…

Issue: Patient A received a Certificate of Medical Necessity for Patient B and lab reports on Patient C in the mail along with the medical information that he requested. The documents contained Patient B's and C's name and full SSN. Update:…

Outcome: The original hard copy record was retrieved and the 2 patient misfiled documents were found in the record. The misfiled documents were removed from the record and filed properly. ROI supervisor instructed ROI staff on importance of reviewing all documents…

Issue: A manual was developed for use in training and distributed to timekeepers at their annual meeting. Four pages in the manual were not redacted. Two pages had the employee's full name. Two pages had the employee's full name and full…

Outcome: The Privacy Officer has discussed with the Fiscal Service that any materials used for training purposes must first be reviewed by the Privacy Officer. Fiscal was not aware and will comply for any future training materials they developed.…

Issue: Veteran called to report that he had received information in the mail that was not his. The information received was a denial letter sent by VA Illiana Health Care System Fee Basis employee. The name was the same as his;…

Outcome: Education will be given to all employees involved. The process will be looked at for a possible systems redesign. The mis-mailed information was retrieved and is back in our control.…

Issue: A VA Provider mailed a letter to Patient A with his lab results embedded in the letter. Included in Patient A's envelope were letters for Patient B and C. Those letters contained Patient B's and Patient C's names, addresses and…

Outcome: Provider was educated to be more careful when mailing letters to patients to assure each letter is in its own envelope, and to have follow proper procedures with having a co-worker double check her envelopes prior to mailing.

Issue: A VA Pharmacy staff employee dispensed medication to the wrong Veteran in error. Veteran A received Veteran B's prescription that was intended for UPS delivery. The employee mistakenly placed Veteran B's medication in a bag with other medications appropriately prescribed…

Outcome: Prescription medication was returned, dispensing process was reviewed and employee counseled on best practices to ensure this mistake does not happen in the future.