VA Mid South Healthcare Network (VISN 9)

Report ID: SPE000000079359, U.S. Department of Veterans Affairs

Reported Entity: VISN 09 Nashville, TN

Issue:

The Privacy Officer was contacted by Chief, Pharmacy regarding the following:A Veteran contacted the pharmacy to report he did not receive his controlled medication in the mail. Upon inquiry, Pharmacy found the medication was delivered on August 18, 2012, but Veteran stated he did not receive it. Veteran was given the tracking number and went to the post office where he obtained a Track/Confirm Intranet Item Inquiry which showed the signature and address where the medication had been delivered and signed for. The address was the Veterans former address (The current address is in the system). Chief, Pharmacy ran a query on Veterans address and found:On August 14, 2012, Veterans address was changed from his current address to his former address via a phone call to the Business Office (BO), Murfreesboro Campus. On August 15, 2012, Veterans address was changed from the former address to the current one also via a phone call to the BO, Murfreesboro Campus. The Veteran stated he did not request the address changes. Another individual (unknown to this Veteran) signed for the controlled medication. The clerk, who completed the address changes, does not recall this specific case. However, the clerk stated Pharmacy routinely transfers patients to him and he completes address changes over the phone.According to the Chief of the Business Office, no change of address should be completed over the phone. A Veteran must present in person show a picture ID, and the make the address change request. The change is completed immediately. Chief of the Business Office will reiterate the process for address change requests to all BO staff. The clerk involved will receive individual education. The Postal Service bears some responsibility as the mailman did not validate the signature upon delivery. Chief, Pharmacy will contact the Postmaster and ask for assistance with retrieving the package.Veterans Personal Identifiable Information includes: full name, address, name of medication(s). Update: 08/21/12: The Veteran will be sent a notification letter.

Outcome:

8/28/12 - Upon inquiry, the Pharmacy, Nashville Campus, found the medication was delivered to the Veteran's previous address on August 18, 2012 and signed for by an individual unknown to him. The Chief, Pharmacy ran a query on the Veteran's address and found: On August 14, 2012, the Veteran's address was changed from his current address to his former address via a phone call to the Business Office, Murfreesboro Campus. On August 15, 2012, Veteran's address was changed from the former address to the current address also via a phone call to the Business Office, Murfreesboro Campus. Veteran stated he did not request these changes. It is unclear who requested the changes. The Chief, Business Office, will review our process to determine the appropriate mechanism to complete address change requests. HIPAA Notification letter mailed to Veteran.

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: SPE000000079348