Northwest Network (VISN 20)

Issue: A man identifying himself as Veteran A presented himself in the Emergency Department asking for treatment. The man received a wristband with Veteran A's full name, full SSN and DOB when he was triaged and placed in an exam room…

Outcome: Our Emergency Department will be modifying their check-in procedures to prevent this from happening again.

Issue: Medical records were faxed to the wrong number. The office who received the records called to notify this facility. The office stated they would shred the records. The individual who took the call failed to get any contact information from…

Outcome: NOTIFIED STAFF OF ERROR, REVIEWED TRAINING, REVIEWED PROCESSES, SENT OUT CREDIT MONITORING LETTER

Issue: Medical Staff Affairs mailed one veterans lab information to a different veteran (veteran received the correct lab & the incorrect lab). This veteran took all lab work to an appointment outside the VA. This outside provider contacted the VA to…

Outcome: PO continue to talk with and train staff.

Issue: A VA employee disclosed 7332 protected information to the state accident insurance fund. Update: 04/25/12:Veteran A will receive a notification letter.…

Outcome: PO spoke with the employee and their Supervisor. The employee didn't remember doing the release so I reviewed the ROI training and cited 1605.1.SENT NOTIFICATION LETTER.…

Issue: The Chief of MAS was walking through the clinic area and saw a clinical staff member (Tech) leaning over the clerk counter and talking to a Veteran who was standing in the waiting room area. The technician was speaking to…

Outcome: PO requested employee retake Privacy & HIPAA Training 2012 and submit signed certificate by 5-2-2012. PO sent report to Supervisor and HR for potential further action.

Issue: Veteran A had his information mis-mailed to another individual. The documentation included Veteran A's medical information and full SSN. Update: 04/19/12:Veteran A will be sent an offer for credit protection services.…

Outcome: The staff responsible for sending the lab results to the incorrect patient and address have been educated on the proper procedures for mailing documentation to our Veterans. The supervisors have provided assurance that all mailings will be reviewed twice prior…

Issue: Records requested by the Veteran were sent to military duty station instead of the home address. The records included his name, address, date of birth, full SSN and protected health information. Update: 04/11/12:Veteran A will be sent a letter offering…

Outcome: INFORMED CLERK OF ERROR AND INSRUCTED THEM TO READ THE WHOLE DOCUMENT WHEN RELEASING RECORDS. SENT OUT CREDIT MONITORING LETTER.…

Issue: A medical record was mailed to the wrong Social Security Administration office. Update: 04/05/12:The records were requested from the Arizona Department of Economic Security and were sent to the Oregon branch of the Social Security Administration. It has not been…

Outcome: ATTEMPTING TO CONTACT RECIEVING OFFICE. SENT OUT CREDIT MONITORING LETTER. INFORMED STAFF OF ERROR. REVIEWED PROCEDURES AND REVIEWED TRAINING.…

Issue: A VA Provider involved in a tort and peer review case reported to another VA employee she had let her husband (who is not a VA employee) review records and help her with her response letter for the tort and/or…

Outcome: Director signed PO report and for action - the report needed to be referred to HR and Supervisor to determine if administrative action is warranted.

Issue: A Provider change request form containing Veteran A's full name, last four of SSN, date of birth, phone number, and address was given to Veteran B. Update: 04/04/12:Veteran A will be sent a letter offering credit protection services due to…

Outcome: DOCUMENT WAS RECOVERED. NOTIFIED STAFF OF INCIDENT. INSTRUCTED STAFF TO BE AWARE OF ANY DOCUMENTATION ON DESK. SENT OUT CREDIT MONITORING LETTER.…