Veterans In Partnership (VISN 11)

Issue: A UPS package containing two controlled substance prescriptions inside are reported as lost/stolen from UPS in the West Lafayette, IN shipping depot. This package was last reported as "attempted to sign" at the patients door but patient was unavailable for…

Outcome: Credit Monitoring Letter mailed to Veteran. This was not a VA error.…

Issue: 2 Biomedical PCs were removed from the facility by the vendor without the hard drives being sanitized. The hard drives contain PII and PHI. The vendor is still in possession of the PCs. Update: 03/01/11:The ISO states that the risk…

Outcome: The vendor was provided additional information on Veterans Affairs Ann Arbor Health Care System (VAAAHS) property and inventory management that provides details of the appropriate steps to take before removing VA property from the facility. VAAAHS staff will remain vigilant…

Issue: A guest visiting VAIHCS was waiting in the Medical Library and found the papers laying on a table. The guest recognized that the information should not be laying around and turned in the papers to the library staff. Update: 02/25/11:Veteran…

Outcome: Disciplinary action of employee is proposed by HR.

Issue: HR Specialist was sending financial (bank account numbers) information as well as full SSN among other information to Employee A but instead it went to Employee B with the same name. It is unknown at this time if Employee A…

Outcome: Supervisors have met with the employee and developed a new process to notify participants of their service period ending. They will no longer attach any forms in an email message. The employee must come to the office to pick-up the…

Issue: VA employee mailed Veteran A's medical record to the attorney of Veteran B. Both Veteran A and Veteran B have the same last name and attorneys for both Veterans had requested their clients medical records during the same time period.…

Outcome: Written Counseling was issued.

Issue: A VA employee discovered paperwork in a Public Restroom within the Medical Center. The paperwork was on two different patients and included SSN, DOB, Claims information, and Medical Diagnosis. Update: 02/16/11:Two (2) Veterans will receive a letter offering credit protection…

Outcome: The employee involved in this incident has retaken awareness training and has been counseled.

Issue: Veteran's son reported to staff at VA Illiana CBOC (Lafayette) that included with his father's (Veteran patient) information mailed to him, additional patient records were in the envelope. Envelope is being returned to VA for additional investigation. Update: 02/16/11:Veteran A…

Outcome: The information was mailed from VAIHCS Release of Information Department. Chief, HIMS has talked with Release of Information clerks and has educated them on a new process where ROI requests will be processed one at a time and fully completed…

Issue: An Outpatient Pharmacist mistakenly gave Veteran A's prescription to Veteran B. Veteran A presented to collect the prescription and the Pharmacist discovered the error. The Pharmacist contacted Veteran B and directed Veteran B to dispose of Veteran A's medicaiton bottle…

Outcome: Notification letter sent to Veteran. Veteran identification process reviewed, employee involved has received verbal counseling on the proper process to follow.…

Issue: Vet was transferred from one ward to another and in the process his Social Security Card, Michigan ID card, birth certificate and insurance card was identified as missing. Update: 02/10/11:Veteran will receive a letter offering credit protection services since their…

Outcome: Supervisor is working on SOP for staff and providing additional education on the process. In addition if patient is being received from ER, a hard copy document is completed "personal property". Upon transfer, pt belongings are documented on the admission…

Issue: ROI employee accidently mailed Veteran A's medical information to Veteran B Update: 02/09/11:Veteran A will receive a letter offering credit protection services.…

Outcome: Employee re-educated and letter offering credit protection sent out.