Veterans In Partnership (VISN 11)

Issue: Veteran A's approval letter was inappropriately sent to Veteran B. Update: 03/25/13:Veteran A will be sent a letter offering credit protection services, as his date of birth and other medical information was disclosed.NOTE: There were a total of 18 Mis-Mailed…

Outcome: Credit monitoring letter has been sent to the impacted Veteran, employee has been educated on error and reassigned to other duties.

Issue: A preventive medicine note regarding Veteran A was inappropriately documented in Veteran B's electronic medical record. To compound the error Veteran B's full name, full SSN and DOB were disclosed to Veteran A when he was given and educational copy…

Outcome: Credit Monitoring letter has been sent to impacted Veteran, education has been provided to clinical nursing staff regarding the proper identification of Veteran/patient, prior to any procedures, charting or releasing of educational materials (medical records).

Issue: A Veteran (Veteran A) was in a program and brought his medications with him. The Veteran turned them over to the VA until the program was complete. When the Veteran was discharged, the medication was left behind.The Pharmacy mailed the…

Outcome: The pharmacy is re-educating the staff to double check all names on medication bottles prior to mailing them to the Veteran.

Issue: Veteran A contacted Registration to report receipt of letter that belonged to Veteran B. Update: 03/15/13:Veteran B will be sent a letter offering credit protection services, as his full SSN was disclosed.…

Outcome: Per supervisor, they are revamping the way correspondence is mailed to Veterans.

Issue: A Grand Rapids Community Based Outpatient Clinic (CBOC) LPN inappropriately accessed a Veteran's (former spouse) electronic medical record. A Sensitive Patient Access Report (SPAR) has confirmed two instances of this employee's access to the Veteran's electronic medical record. Update: 03/06/13:The…

Outcome: Inappropriate access to the medical record has been confirmed. Appropriate disciplinary action has been recommended. PO/ISO report has been provided to the supervisor, CBOC manager and Labor Relations for appropriate action. Notification letter has been sent to the Veteran.…

Issue: The Privacy Officer (PO) received a call from telephone triage indicating that Veteran A called to state mail was received that contained the name, address, full SSN and lab results of Veteran B. Update: 03/07/13Veteran B will receive a letter…

Outcome: Per Supervisor, they have changed their SOP to include initials of anyone mailing letters to insure accountability of staff and error reduction.

Issue: A Veteran received two other Veterans' appointment reminder letters. Update: 03/04/13:Two Veterans will be sent a notification letters.…

Outcome: Service provided re education.

Issue: Insulin medication was mailed to Patient A and Patient B. Patient A received Patient B's medication and Patient B received Patient A's medication. Update: 03/04/13:Patient A and B will be sent a notification letter.NOTE: There were a total of 97…

Outcome: The Pharmacy supervisor has advised the staff in regards to this incident report, and instructed them to double check the contents against the mailing label.

Issue: HR assistant stated that the civilian army record of a new employee was requested from the National Personnel Records Center (NPRC) so HR could give appropriate work history credit, pay etc. Record was requested in August and never received. HR…

Outcome: Although HR Specialist not 100% sure the record never reached this facility, they will continue to search all areas within and outside of the department. For any future record requests, they will request that the National Personnel Records Center mail…

Issue: Veteran A stopped by registration to get his travel pay. She presented her mileage voucher to the registration window. Attached to the voucher slip was an outpatient routing slip for Veteran B that included Veteran B's name, address, full SSN…

Outcome: Supervisor has provided additional training to staff on the need to review all documents for accuracy before giving to Veterans.