Issue: An inpatient arm band was discovered attached to a wheel chair in the wheelchair repair clinic at VA Illiana Health Care System. The arm band contained a patient's name, full social security number and date of birth. The wheelchair repair…

Outcome: The Chief Nurse of the Community Living Center provided education to all staff instructing them not to print out inpatient arm bands for the use of identifying the owner of personal equipment of patients such as wheel chairs, walkers, etc.…

Issue: Veteran (son) and Veteran (father) have same name. Prescription intended for son ordered in father's record. Prescription went to father. Father notified VA of error. Update: 01/18/11:The son will receive a letter of notification since his medication information was exposed.…

Outcome: Letter to Veteran. Educated staff on safeguards, need to be accurate.…

Issue: On or about 12/13/10 4 prescription bottles for Patient A were removed from the Tucson Consolidated Mail Outpatient Pharmacy (CMOP). These bottles were not recovered but a Logistic Staff member admitted to stealing the medication and throwing away bottles. On…

Outcome: The logistic staff member is no longer employed by the CMOP.

Issue: A Veteran had an appointment at one of our CBOC's on 1/10/11. At the end of that appointment, he was given a Medication Reconciliation Note by A nurse. He did not review this document until this past weekend and at…

Outcome: The employee invovled with this incident was re-trained and provided education on double checking documents with ID of Veteran.

Issue: A veteran called to say that he received the medical record of another veteran instead of receiving his own information. Update: 01/19/11:Veteran will receive a letter offering credit protection services since his full SSN and DOB was exposed.…

Outcome: Supervisor has counseled employee.

Issue: Progress Note for Veteran A discovered in paper copy of Veteran B's records. Progress note contained 7332 information. Document returned to VA by Veteran B. Note had been placed in Veteran B's record in September, 2006. Note was discovered by…

Outcome: Responsible employee counseled by Supervisor, re-educated by Privacy Officer.

Issue: What Occurred: On 1/12/2011, Veteran #1 notified the Medical Specialty Care Clinic Administrative Officer that his VAMC appointment letter envelope included an enclosure with six upcoming medical appointments intended for another Veteran. According to Veteran #1, he intends to locate…

Outcome: Corrective Action: Employees have been educated on the need to safeguard patient information. Letter of notification was mailed to the Veteran on 1/21/2011. Please close out ticket.…

Issue: Credentialing and Privleging file reported missing from the locked file room Update: 01/20/11:Employee A will receive a letter offering credit protection services.…

Outcome: Access to file room will be greatly reduced.

Issue: Veteran A signed for his medication but did not pick up his Bag. He returned to the pickup window stating that he forgothis medications, but his bag was gone.We noticed that veteran B was the next person to sign for…

Outcome: Employee cautioned to check box before placing more medication there.Privacy notification letter sent to veteran

Issue: Home Health Nursing Agency Representative reported that nursing sheets from October 1 - October 20 on one veteran cannot be located. Am waiting for more information on what actual information was on the sheets that were lost. Update: 01/21/11:Patient A…

Outcome: The owner of the Home Health Agency has implemented a new policy that will ensure that the nursing sheets are never hand carried by anyone but her - in a locked briefcase from the veteran's home to a locked cabinet…