Veterans In Partnership (VISN 11)

Issue: Veteran/employee A went to the pharmacy to pick up his medications. He was only given two medications and he said his medication sheet listed four medications. He handed his medication sheet to the pharmacy tech who realized the sheet belonged…

Outcome: The Emergency Room Nurse Supervisor met with all ER Nursing staff and mandated that upon returning to the exam room with the printed discharge note, the staff again verify the patient identifiers (name and date of birth) with the Veteran,…

Issue: VA Employee A reported that Employee B who is an Ophthalmology Tech had her boyfriend in the room while she was examining a patient. Update: 08/22/12:Patient A will be sent a notification letter.…

Outcome: The Ophthalmology Technician has been reminded of her responsibility to protect the privacy of our patients information. There will be additional administrative action once the investigation is completed.

Issue: A VA Physician allowed her spouse to job shadow and then allowed him to access a computer that she was logged into. Update: 08/20/12:The physician is not scheduled for duty until Tuesday Aug 21. Her computer access has been disabled…

Outcome: The physician came into work today and she was counseled on the Rules of Behavior by her supervisor. She has taken the Privacy and HIPAA training. The spouse had no access to patient records or confidential information. It was determined…

Issue: Veteran A requested his DD-214 from ROI. The ROI clerk sent Veteran B's DD-214 accidently. Veteran A called the facility immediately upon receipt. The Privacy Officer mailed an envelope to Veteran A. He sent the DD-214 back to the Privacy…

Outcome: ROI supervisor will re-educate the ROI clerk on double checking all information before sending any records out. She will also review the SOP with the clerk.…

Issue: Veteran A contacted VA Illiana Health Care System (VAIHCS) Imaging Department and indicated that on 7/23/12 he had a CT with an IMED consent form signed and was given a copy of the consent. When Veteran A came back to…

Outcome: Action taken by service to put a process in place to ensure this does not happen again. All staff in the service educated with the new process.…

Issue: A Veteran met a VA employee on an internet-dating website. The Veteran stated that the employee said the Veteran had not received a Mental Exam prior to leaving Active Duty. The Veteran asked the employee, "How do you know that?"…

Outcome: The Privacy Officer (PO) and Supervisor discussed with the employee the need to keep personal life apart from work. Should another Veteran be encountered employee must have the Veteran go through normal procedures to participate in specific programs and to…

Issue: On August 9, 2012, @ 4:30 p.m., Veteran A called Medical Center Alt. Privacy Officer, and reported having been discharged from the Medical Center's PTSD Residential Rehabilitation program, at 11:30 a.m., 7/27/2012., and that a second Veteran - Veteran B,…

Outcome: CM Letters have been sent to the Veterans involved with this incident. Service Chief has educated the employee responsible.…

Issue: Patient A received a letter from his physician regarding an update on his condition. In the same mailing envelope Patient A also received a letter regarding Patient B. That letter included Patient B's full name and address and results of…

Outcome: Patient B's physician letter was retrieved from Patient A. A notification letter was mailed to Patient B along with the physician letter. The clerks that mail out the physician letters were given email awareness training of the importance to take…

Issue: Veteran A received a letter with the name and medical diagnosis information that belonged to Veteran B. Update: 08/06/12:Veteran B will be sent a HIPAA notification letter since his medical information was disclosed.NOTE: There were a total of 22 Mis-Mailed…

Outcome: The supervisor has conducted training with all staff on the need to review all documents before mailing to insure mis-mailings do not occur.

Issue: A holter monitor was packaged and sent via Contract Lab Courier in a locked box from a Community Based Outpatient Clinic (CBOC) to the Main Hospital. The lock box was delivered to the Lab but the holter monitor was never…

Outcome: A credit monitoring letter has been mailed to the Veteran. A new process is being developed to track and secure the holter monitors. Since this ticket was entered, the holter has been found at the facility. The Veteran was contacted…