Northwest Network (VISN 20)

Issue: Patient A found a folder containing the progress notes and medication lists for Patient B. The folder contained a social worker's business card with her contact information. Patient A handed the folder to the cashier, who then handed the folder…

Outcome: VA staff responded expeditiously in reporting the incident to the Privacy Office, and ensuring that the PHI was secured shortly after the folder was discovered.

Issue: The Privacy Officer (PO) pulled a list of everyone who has accessed a CPRS record this week for a provider who passed away over the weekend. The PO found one employee had accessed the provider's record on Monday morning after…

Outcome: HR/Supervisor to get a copy of the investigation report for further action.

Issue: A VA Employee on a treatment team received a call from Veteran A who stated he received a letter from the VA that contained a print out of Veteran B's information (full name, full SSN, medical information, and DOB. The…

Outcome: Veteran mailed back the contents of the letter, have received retrieval of the documents. Team notified of the incident and educated on the importance of checking the envelope.

Issue: A document with 30 pages of neurology notes from a Veteran's medical record were mistakenly faxed to a public school instead of to the hospital who had requested them. The error occurred by one digit of the fax number being…

Outcome: All pages of the mis-faxed documents were received back from the recipient and are accounted for. All ROI staff have been reminded to be cautious of misdialing outgoing faxes.

Issue: A letter notifying Veteran A that his VA provider had scheduled a clinic appointment for him was mis-mailed to Veteran B who has the same last name. Veteran B brought the letter to the local Patient Advocate's office to report…

Outcome: A notification letter has been sent and the employee responsible has been counseled on the need to protect sensitive information.

Issue: Veteran A's lab reports were included in records sent to Veteran B. Update: 04/02/12:The Privacy Officer is waiting the return of the reports to determine what data was exposed. This will determine whether notification or credit protection services are required.04/10/12:Veteran…

Outcome: NOTIFIED CLERK AND SUPERVISOR OF ERROR. REVIEWED TRAINING AND PROCESSES. MAILED OUT CREDIT MONITORING LETTER.…

Issue: The Director's Office sent a C-File with our VA employed van driver to drop off the chart to the mail room. The chart was to be sent back via UPS to Washington D.C. They called us to state they never…

Outcome: We are looking at persons to hand deliver C&P Files to the mail room and waiting for the UPS tracking label instead of giving them to our VA Employed Courier. The courier goes so many places and dropped off the…

Issue: Veteran A was mismailed Veteran B's PHI. Both Veterans have very similar names. Veteran A seeing that the mailed information was not his own, brought it into the VAMC and gave it to the Scheduling Clerk. Additionally Veteran A wanted…

Outcome: Employee found responsible was counseled by Supervisor. Safeguard processes were reviewed with employee. Proper identification procedures will be practiced going forward.…

Issue: A Veteran's VA Provider contacted the facility Privacy Officer to discuss the Veteran's desire to revoke authorization he had signed allowing his mother and father from communicating with his providers about his treatment. The Veteran will be submitting a written…

Outcome: The employee has been counseled by the Privacy Officer and department Supervisor regarding our requirements for accessing a Veterans medical record. There will be follow-up reviews of the access to the Veteran's chart to verify there is no further access…

Issue: A VA employee went to a meeting with some documents. He still had control of those documents after the meeting. The meeting ended at 11:00 AM. The employee left approximately 10 minutes later. At 2:00 PM, another VA employee found…

Outcome: The Privacy Officer discussed with the employee the need to, and importance of safeguarding all Veteran information. .…