Veterans In Partnership (VISN 11)

Issue: A nurse left two surgery schedules with labels and wrist bands turned upside down on her desk. When she returned from lunch, everything was missing. The Privacy Officer (PO) asked each of the 3 staff who were at the nursing…

Outcome: When not in use, the procedure lists are locked at the nursing station.

Issue: The Information Security Officer (ISO) was contacted by VA Social Work staff regarding a patients detailed personal information being faxed on 01/16/13, to the Hoptel. The Hoptel is a non-VA contracted hotel where VA outpatients from out of town can…

Outcome: The VA Hotel staff have modified the process for creating hotel reservations for VA patients, so PII is not longer provided to the Hotel contractor. The PO sent a credit monitoring letter to VA Patient (redacted letter is attached to…

Issue: Veteran A was handed an iFOBT test kit at his appointment on 12-11-2012. The plastic tube had the full name, full social security number, and birth date for Veteran B.Veteran A put a piece of paper tape with his name,…

Outcome: Both nursing and medical staff providers are being retrained about verification of information being given to Veterans.

Issue: A preliminary fee remittance advice report was mailed to an incorrect PO Box number in error. Update: 01/17/13:Due to medical information being exposed, Veteran A will be sent a notification letter.…

Outcome: Fee Basis Section employees have been educated on the error and the proper verification of address prior to mailing. Notification letter has been sent to the impacted Veteran.…

Issue: A fecal occult blood test (FOBT) card was handed to Veteran A on 12/28/12. This occurred at a community based outpatient clinic (CBOC). On 1/10/13, Veteran A returned to the CBOC and returned the FOBT card since it contained Veteran…

Outcome: The CBOC staff will be provided with additional training to ensure verification of material given to a Veteran is specifically for that Veteran.

Issue: Patient A returned documents that he received in error about 3 years ago. Patient A made a Release of Information request for his medical records in February 2010. Patient A received his medical records and the medical records "Minimum Data…

Outcome: The Privacy Officer has notified the Release of Information Supervisor of this incident, and VA staff responsible for mailing patient information have been reminded that we are responsible for protecting the privacy of our patients information. VA staff were also…

Issue: In the course of an employee's accommodation request medical information from a prior accommodation request was given to the employees supervisor and then to fellow workers. Update: 02/28/13:The employee will be provided notification.…

Outcome: VA employee received verbal counseling and education for his mistaken act of disseminating Veteran/employee health information.…

Issue: Veteran A's prescription medication was dispensed to Veteran B. Veteran B realized the error and returned the medication to the Pharmacy. Veteran A's name and type of medication was disclosed. Update: 01/02/13:Veteran A will be sent a notification letter due…

Outcome: All Pharmacy staff will be re-educated on the need to check Veteran's names with the medication before dispensing.

Issue: Veteran A was issued a new CPAP (breathing machine issued by Sleep Lab) as Veteran A was having problems with the machine working properly. During the course of the conversation the nurse taking care of Veteran A examined the machine…

Outcome: Staff have been trained to verify CPAP (continuous positive airway pressure) download cards before issuance.

Issue: A Clinical employee who was temporarily reassigned from normal duties had several leave and earning statements come up missing. A thorough search was completed by the respective service. The search located some but not all of the statements, pay periods,…

Outcome: LES handling procedures have been reviewed and improved upon in order to prevent a similar occurrence in the future. Notification letter has been sent to the employee involved in this incident.…