Northwest Network (VISN 20)

Issue: On May 1st Veteran A came in to pick up a prescription and also received 2 prescriptions for Veteran B . We were able to contact Veteran A to get the prescription back as well as the information sheet that…

Outcome: We spoke to the company that handles the Script Pro machine and they said they were working on a computer patch to correct the machine's multiple people's medication in one box errors. The Pharmacy Supervisor said until the Patch is…

Issue: The wrong Patient's information was sent in response to a release of information. The ROI clerk sent information on a Patient with the same first and last name to a requesting attorney. The person the request was for is not…

Outcome: Employee was counseled on reviewing release of informations more toughly. A checklist was created to assist the ROI clerks with verifying patient identifiers and completeness of request. Supervisor will also scrutinize the request and the records more.…

Issue: VA gave Veteran A a printed 'Health Care Plan' with the wrong full SSN on it. The SSN belongs to Veteran B. Update: 03/28/13:One Veteran will be sent a letter offering credit protection services.…

Outcome: Credit Monitoring Letter has been signed and mailed out. Staff have been counseled and re-educated on Information Security.…

Issue: Pharmacy received a call today from [Reporting Veteran], stating that [they] had received medications for 3 other veterans along with [their] refrigerated medications. I did some preliminary investigating to try to determine where the error occurred. The only conclusion was…

Outcome: The Facility Privacy Officer (PO), Mikel Beckham, conducted a thorough investigation into the cause of the miss mailing and determined it to be human error, not double checking the yellow address label affixed by pharmacy prior to attaching the UPS…

Issue: On March 20, 2013 Veterans A and B were seen by the same VA Provider in back to back appointments. When Veteran A left the clinic he was given his After Visit Summary as well as the summary for Veteran…

Outcome: NA

Issue: A Veteran brought in a letter she received in the mail. In the envelope was another letter addressed to a different Veteran and a progress note for another. Update: 03/18/13:Due to full SSN and medical information being exposed, Veteran B…

Outcome: The admin staff in the clinic that mailed the letter were retrained (retook the Privacy training) and the service reminded them it is their practice to double check mailings when stuffing envelopes.

Issue: An employee improperly accessed the record of a Veteran/Employee. Update: 03/14/13:The employee who accessed the record did not recall why the record was accessed since this occurred in January, 2013. The position the employee held at the time did not…

Outcome: Notification letter sent out. Supervisor notified. Training provided.…

Issue: On 02/15/13, a contract staff member at a Community Based Outpatient Clinic (CBOC) discovered she had given Patient A's medication list to Patient B. Staff contact Patient B, confirmed this, and requested the return of the medication list. The list…

Outcome: Noted in the initial report, the CBOC staff were reeducated on policy and instructed to retake the national Privacy training.

Issue: A VA provider had his appointment book stolen on 02/27/13. It contained the first and last initials and last 4 digits of the SSNs for 13 Veterans and the date, time, and abbreviation for the clinic location the provider met…

Outcome: NA

Issue: Veteran A was sent medical records requested from the Portland VAMC and with the records that were mailed to him on 02/08/13 was a 1-page EKG document for Veteran B. Veteran A mailed this back to the facility with a…

Outcome: NA