Veterans In Partnership (VISN 11)

Issue: A VA Employee mailed a lab results letter to a patient and also mailed two additional patients lab results letters to that same patient. The letters included the patients full name and lab results. It did not include the patients'…

Outcome: The Privacy Officer has notified the Ambulatory Care Supervisor of this incident and VA staff responsible for mailing patient information have been reminded that we are all responsible for protecting the privacy of our patients information and to take the…

Issue: A Compensation Work Therapy (CWT) worker found new equipment still in boxes in the dumpster. Upon retrieval of the equipment along with VA Police and Logistics Supervisor, they also found 2 boxes with full address labels, addressed to 2 Veterans.…

Outcome: Prosthetics Supervisor and Logistics Supervisor will train their staff on proper disposition of equipment with use of form 2237 and proper disposition of item that contain the Veteran's Personally Identifiable Information (PII).

Issue: Two Veterans were in the hospital on the same day and a radiology report for Veteran B was given to Veteran A at discharge. The Veteran's wife contacted telephone triage to ask some questions and it was found out then…

Outcome: The supervisor has instructed all staff on the following:Please make sure that when you are pulling items off the printer that you check each paper you pick up to make sure it is for the Veteran you requested an item…

Issue: A recently retired Nutrition and Food service worker's Agency Certification of Insurance Status was inappropriately uploaded into another employee's eOPF account. The document contained the retired worker's name, date of birth and full SSN. Update: 10/17/12:The employee received a notification…

Outcome: HR staff have been educated to ensure they are scanning records into the correct employee's eOPF file. Credit monitoring letter has been sent to the impacted employee.…

Issue: A correspondence was sent to a Veteran/Patient and the address label on letter contained his full SSN. Update: 10/16/12:The Veteran will be sent a letter offering credit protection services due to full SSN being exposed.…

Outcome: No violation found as PO was unable to ascertain who in fact sent the correspondence. The printer that was used, is used for chart labels and has been marked for that purpose only as far as future use and not…

Issue: A test results notification letter and lab results for Veteran A were mailed to Veteran B in error. Update: 10/16/12:Veteran A will be sent a notification letter due to PHI being disclosed.…

Outcome: Letters have been returned, employee has been educated on the error and letter mailing process. Notification letter has been sent to the impacted Veteran.…

Issue: A telephone triage note pertaining to Veteran A was given to Veteran B in error. Update: 10/16/12:Veteran A will be sent a letter offering credit protection services.…

Outcome: Education has been provided to employees who are involved in this process. Credit monitoring/notification letter has been sent to the impacted Veteran.…

Issue: Veteran/Patient A returned Patient B's "Inventory of Belongings" form, that was mistakenly given to Patient A when he was discharged from the hospital. The report includes Patient B's full name and full SSN and DOB Update: 10/10/12:Veteran B will be…

Outcome: Mental Health Staff filed a VAAAHS incident report on this incident. PO requested an update of process improvement activities to prevent this type of error from reoccurring.…

Issue: A CBOC sent 6 prescriptions for 5 Veterans and a list via USPS to our Fort Wayne facility. The package was received in the mail room and taken to the pharmacy. The envelope was opened in the pharmacy and the…

Outcome: The pharmacy has instituted the following:Prescriptions from CBOCs will now be sent by UPS. This will allow for them to be delivered directly to the pharmacy instead of going through the mail room.These envelopes are to go to the pharmacy…

Issue: Veteran states that their privacy was violated when a pharmacy technician at VA Illiana Danville facility said the names of their medications loudly so that others in the line behind her could hear. Update: 10/04/12:One Veteran will be sent a…

Outcome: Outpatient pharmacy supervisor and pharmacy employee have been given oral counseling and education to use the secure pharmacy consultation room when talking with this Veteran in the future. Also, pharmacy employees have been instructed to offer the use of the…