Issue: Missing medical record. File room personnel report transporting it to Community Based Outpatient Clinic (CBOC). CBOC personnel have no record of receiving it. Update: 01/13/11:Due to PHI and full SSN,Veteran A will receive a letter offering credit protection services.…

Outcome: When transporting medical records between file room and CBOCs, all future requests will be forwarded with a trip ticket and return receipt, specific for medical records.

Issue: On December 20, 2010, a Rx for Patient A was handed to Patient B. Patient B returned the sealed package unopened to the pharmacy, but he may have seen the name of the medication prescribed for Patient A. Update: 01/13/11:Veteran…

Outcome: Education provided

Issue: A Pharmacy envelope with medication mailed to a veteran was returned via USPS(United States Postal Service) opened to the Mail room without its contents. An opened envelope was received by the VA mail clerk via USPS contained all of the…

Outcome: TVAMC has communicated with ScriptPro, automatic prescription filling device vendor, with a request to reformat the date of birth on the prescription label and bag label so that it is not identifiable as a date of birth. Staff can be…

Issue: Veteran A's radiology report was mis-mailed to Veteran B by a clerk in Release of Information. Update: 01/13/11:Veteran A will receive a letter offering credit protection services.…

Outcome: The ROI clerk has been provided additional training by Privacy Office and couseled by supervisor.

Issue: misdirected mail with full SSN, not found. Update: 01/18/11: Due to the fact that the originial mail was not loctated, Veteran A will receive a letter offering credit protection services.…

Outcome: ROI supervisor and staff counseled for attentiveness to the possibility of multiple addresses in ROI system and need to reference the active request for current information.

Issue: The pharmacy Administrative Officer reported that her emergency call back "cascade" report has been stored on the Pharmacy's shared drive since 2005 and has been routinely updated as the employees' information changed. The report is used when it is necessary…

Outcome: A broadcast message was sent to all medical center staff asking them to review all shared folders and files to which they currently have access. Staff were asked to ensure that they still need the access as part of their…

Issue: Credentialing and Privileging folder of potential nurse was discovered missing from the C&P office. Update: 01/14/11:Nurse will receive a letter offering credit protection services since her full SSN and DOB was exposed.…

Outcome: New systems have been put in place.

Issue: Veteran had an appointment list after leaving appointment with primary care provider. Update: 01/14/11: PO states there weres eight names on the list. The list did not leave the facility and was returned to VA employee custody in less than…

Outcome: Staff and Supervisors reminded of precautions to take and responsibility for timely reporting of incidents.

Issue: Upon discharge an RN inappropriately disclosed a ward census report to a Veteran. The census report was attached to the Veteran's discharge instructions. 30 full names and full social security numbers were disclosed. Update: 01/14/11:Thirty (30) Veterans will receive a…

Outcome: Provided additional privacy training to employee involved and encouraged all staff to double check the information retrieved off the printers. Supervisor also spoke with employee. Mailed credit monitor letters to 29 Veterans involved in this incident.…

Issue: On 1/4/2011 Veteran #1 received a reminder by mail of an upcoming Mental Health appointment. The Veteran realized that a second Mental Health appointment letter which was intended for another Veteran was attached to his letter. The Greenville SC CBOC…

Outcome: Employees were educated on the need to safeguard patient information.