VA Southwest Health Care Network (VISN 18)

Report ID: SPE000000068634, U.S. Department of Veterans Affairs

Reported Entity: VISN 18 Phoenix, AZ

Issue:

Today, 11/14/11, a Nurse Manager reported to the Privacy Officer (PO) that he observed clinical staff scanning what appeared to be a paper bar coded document while dispensing medications on Thursday, 11/10/11. After identifying this apparent work-around for the bar code medication administration (BCMA) dispensing system , the materials were retrieved for further inspection. The employee explained that the booklet of bar codes was kept in her uniform pocket, and taken with her when she leaves. The oldest discharged patient initially was from 08/18/11, confirming probable off-campus transport of the booklet. The investigation commenced today, the next business day. Review of the materials by the manager and the PO indicates use of approximately 23 resident patients' name, full SSNs and with a variety of medication bar codes to dispense medications. No narcotics. Stacking of patient bar code labels indicate developed use of this tool. Today, the Nurse Manager interviewed the employee with representation. The employee\xe2\x80\x99s representative advised no further discussion and the interview concluded. The scope of exposure of this protected health information (PHI) is unknown. Prior similar in-house materials noted on Environment Of Care rounds mid-2010 resulted in further clinical administrative directives prohibiting this practice. Update: 11/17/2011: After further investigation, there were a total of 25 patient bar codes taken off-site that can be read by a standard bar code reader application on a smart phone. The reader pulls up the name, full SSN, ward, and date of birth. The 25 Veterans will be offered credit protection services. NOTE: There were a total of 15 Mis-Handling incidents this reporting period. Because of repetition, the other 14 are not included in this report, but are included in the "Mis-Handling Incidents" count at the end of this report. In all incidents, Veterans will receive a notification letter and/or credit monitoring will be offered if appropriate.

Outcome:

Appropriate disciplinary measures are being addressed by Nurse Manager and HR. Additional education to this unit provided by Nursing management regarding appropropriate use of medication bar codes. Further monitoring in place by Nurse Manager. Nursing Administration plans to have all nursing staff sign a memo explaining that Privacy violations are subject to disciplinary actions.