Veterans In Partnership (VISN 11)

Issue: An inpatient psychiatrist created 3x5 index cards with patient information to include date of admission, first and last name, last four of SSN, diagnosis, prescribed medications, patient medical complaints/issues, history of present illness, age and date of birth of the…

Outcome: Employee has been educated on the use of paper "logs". Service has also informed all providers that use of these types of cards is not allowed. Credit monitoring letters have been sent to the impacted Veterans.…

Issue: An email alleging inappropriate employee behavior was received and an investigation has started. Said email was forwarded to an email group containing 27 individuals without the "need to know". Email contained the full name of the accused individuals. Update: 07/24/12:The…

Outcome: Employee has been counseled and re-educated. Notification letters sent as directed…

Issue: Veteran A left the clinic and went to the Travel Office. The Travel Clerk recognized that the routing slip belonged to Veteran B and took it to the supervisor who gave it to the PO. It did not appear that…

Outcome: Per supervisor, employee responsible is new and has received additional training or required process for verifying identity of veteran before giving routing slip for travel benefits.

Issue: A medication was improperly delivered to the wrong Veteran. The medication bag was correct but the medication bottle and handout were switched in both bags. The Veteran's name and type of medication were compromised Update: 07/19/12:One Veteran will be sent…

Outcome: Medication and label were retrieved, notification letter sent to Veteran. Pharmacy process was reviewed and employee verbally counseled regarding the error.…

Issue: Patient A received a letter from his physician of 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. No medical diagnosis…

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: The Patient Services Assistant (PSA) gave Patient B's discharge instructions to Patient A. The discharge instructions included Patient B's name, full SSN, date of birth, diagnosis and medication information. Update: 07/12/12:Patient B will be sent a letter ofering credit protection…

Outcome: The information was retrieved. Education and a ROC have been sent to the Supervisor. Credit Monitoring has been done,…

Issue: A Veteran at a contracted Community Based Outpatient Clinic (CBOC) was waiting for his labs to print out. The CBOC employee told the Veteran she would get his labs, turned around to get the labs off the printer and when…

Outcome: The administrative supervisor and the executive director met individually with each employee and discussed the importance of being aware of and protecting patient PHI and private information. A "window block" was placed at check-in and discharge windows to prevent windows…

Issue: Patient A received Patient B's discharge instructions upon checking out of his appointment. Update: 07/02/12:Veteran B will be sent a letter offering credit protection services.…

Outcome: Patient A destroyed the discharge instructions by burning. The supervisor was contacted and a ROC was provided to the supervisor requesting additional training for the employee. The credit monitoring letter has been mailed to the Veteran.…

Issue: The Privacy Officer (PO) was contacted by an employee who found three employee files. The files are in the brown six-part file folder and they all contain the employees" full name, full SSN, credentials, full home address and performance appraisals.…

Outcome: Supervisor has discussed w/employee responsible the need to secure personnel records at all times and where files should be kept when not in use. CM letters have been picked up by employees and PO has attached one of the four…

Issue: Veteran A checked ID band and it had the name and full SSN of Veteran B, Veteran A turned in the armband to another VA employee as Veteran had left the ED and was going to another appointment. Update: 06/19/12:Veteran…

Outcome: Additional training has been provided to staff in areas where armbands are placed on patients with an SOP for reference. Staff member who made the error has also received written counseling.…