Northwest Network (VISN 20)

Issue: Veteran B's medical records were inclued on CD given to Veteran A containing Veteran A's medical records Update: 02/22/12:Due to full SSN and medical information being disclosed, Veteran B will be sent a letter offering credit protection services.…

Outcome: CREDIT MONITORING LETTER SENT OUT. INFORMED SUPERVISOR OF INCIDENT. REVIEWED TRAINING WITH EMPLOYEE.…

Issue: A Physician's Report of Medical Examination (to support of Aid & Attendance) was sent on 02/17/12 in error to the Veteran B. Veteran B who received this information promptly mailed it back to the VA. We received it back on…

Outcome: Staff training was provided.

Issue: A clerk reported to the Privacy Officer (PO) they found a document which they turned into the PO. The document contained two Veterans' information that were admitted on a hospital floor. The information on the document seemed to be a…

Outcome: Residency Program Coordinator to educate resident and attending regarding incident and for safeguarding of information. Notification letters to be sent to two Veterans.

Issue: A Clinic clerk gave Veteran A the appointment slip of Veteran B. Both had the same first name, and the clerk did not double-check the names prior to handing the appointment slip to Veteran A. Veteran A discovered that she…

Outcome: PO has contacted clinic to remind staff to check appointment slips prior to distribution to patients to ensure that info is given to authorized recipients.

Issue: Veteran A called the Portland VA to notify VA that he had been mailed a letter for Veteran B. Veteran A's address had been recorded in Veteran B's record and the letter was correctly addressed to this incorrect address. The…

Outcome: The office where the incorrect address was entered into the affected Veteran's record is aware of how the error occurred and are educating their staff to limit the use of multiple computer windows on the computer screens in their office.

Issue: A Veteran's Prescription was faxed to wrong number, disclosing Veterans A's full SSN, full name and medications. Update: 02/06/12:The Veteran will be sent a letter offering credit protection services, as their name, SSN, and medications were sent to an improper…

Outcome: Mailed out Credit Monitoring letter. Worked with staff to create better processes and practices. Stressed the importance of double checking work to minimize errors.…

Issue: Lab results from Veteran A were sent to Veteran B. Update: 01/31/12:Veteran A will be sent a letter offering credit protection services due to full name and full SSN being exposed.…

Outcome: Mailed out Credit Monitoring letter. PO worked with staff to create better processes and practices. Stressed the importance of double checking work to minimize errors.…

Issue: The Privacy Officer received a packet of medical records that were returned to the VA. When the package was examined, it was noticed it had been opened then retaped and returned to the VA. The package contained records for Veteran…

Outcome: Credit Monitoring letters sent 2-2-2012 to 2 Veterans. Employee was educated and will retake Privacy/HIPAA training and provide copy of signed certificate.

Issue: Veteran A contacted the Portland VA's Transplant department to complain that his health information had been emailed without his authorization to his Aunt on faxed the transplant department a copy of the email his Aunt had received. The facility Privacy…

Outcome: The employee has been counseled not to disclose any Veterans information without having written authorization and a summary of the Privacy Officer's fact finding has been sent to Human Resources for them to determine disciplinary action. A notification letter is…

Issue: Veteran A's wife called to report they received a letter in the mail of another Veterans lab results. (The name of both Veterans is very similar). The lab results were of blood work and had the other Veterans SSN on…

Outcome: The lab results were mailed back from the wrong Veteran. I discussed and educated the clerks involved in addressing envelopes for this Veterans team. Will also be notifying their Supervisor and Director. Privacy Officer notified HR & Supervisor. PO suggests…