Issue: Prescription was mis-mailed to a patient with the same first and last name, however, different last 4. The Veteran that received the medication is supposed to be returning them to LVAMC on 1/13/11. Update: 01/04/11:Patient will receive a letter of…

Outcome: Notification letter sent to Veteran on 1/6/2011

Issue: Two letters were mailed to the wrong veterans; the letters contained sensitive information. Update: 01/05/11:Veterans A and B will receive a letter offering credit protection services.…

Outcome: Supervisor has re-inforced the importance of care when dealing with patient information.

Issue: Job application packages for three individuals were sent via non-trackable method to panel members for review. The package was damaged in transit and information did not arrive to intended recipient. Update: 01/05/11:Three (3) individuals will receive a letter offering credit…

Outcome: We have already implemented additional training for the staff regarding mailing personally identifiable and sensitive information.

Issue: Six medications were mailed to the wrong veteran. The label has another veteran's name and drug on it. Update: 01/06/11:Veteran B will receive a notification letter.…

Outcome: The pharmacy staff was educated on the issue. A notification letter is being sent to the vet.…

Issue: Veteran #1 received his medication along with a UPS package containing medication intended for Veteran #2. Update: 01/06/11:Veteran B will receive a notification letter.…

Outcome: Employees are being educated on the importance of being vigilant when dispensing medications.

Issue: A veteran's PHI was released but had not been authorized for release. The info released included a medication list, Mental Health notes, surgery notes, suicide risk assessments, and other related notes. Update: 01/06/11:Veteran B will receive a notification letter.…

Outcome: This error was made by an experienced ROI clerk who has not had any mistakes reported in the past. Human Resources will be notified of this violation.

Issue: A patient received 161 pages of another veterans medical records from Release of Information. Patient brought the documents back to the Privacy Officer. Name, SSN, and PHI were released. Update: 01/05/11:Veteran will receive a letter offering credit protection services.…

Outcome: PO provided one on one training with clerk and reviewed her processes. Supervisor gave counseling to employee.

Issue: A Santa Maria Psychiatrist mis-mailed a disability form containing SSN, telephone number, health information, date of birth, and address to the incorrect veteran. Update: 01/95/11:Veteran will receive a letter offering credit protection services.…

Outcome: A credit monitoring letter has been mailed to the veteran. The employee reported it and will take additional steps to separate the forms prior to mailing to veterans.

Issue: Mis-mailed medication. Packaging contained the full name, medication and address of the patient. Update: 01/05/11:Veteran will receive a letter of notification.…

Outcome: Notification Letter sent to Veteran on 1/6/2011

Issue: Nurse reported a missing Veteran's medical record. Record included name, SSN, and PHI. Update: PO state the clinic is the Inpatient Ward 5 A. The record been missing since 10/10/10. The last time someone handled or had possession of the…

Outcome: Extra safeguards have been put in place.