Northwest Network (VISN 20)

Issue: Veteran A received a lab results letter in the mail with Veteran B's two page lab results letter folded with it in the same envelope. Upon discovering the error, Veteran A called the VA Health Resource Center (HRC) contact phone…

Outcome: The Privacy Officer is working to identify the office which mailed the envelope to make them aware of the error and prevent future events. The Office is already modifying their procedures for how their staff print and mail letters to…

Issue: The Privacy Officer (PO) received a call from Veteran a who reported that he had received information that was not his. Veteran A was asked to bring this information in to WWVAMC. This was brought in on 12/21/11. It contained…

Outcome: Education provided to the team clerk.

Issue: The door to fax/copy room was left open. The door opens into a high traffic patient area. The lockable lid on confidential disposal bin was left open and the items were accessible to anyone passing in the hallway. Update: 12/22/11:The…

Outcome: PO recommended to supervisor of this area that all staff receive a letter of counseling.

Issue: There were mismailings of appointment confirmation letters and Release of Information forms. Update: 12/15/11:Two Veterans will be sent a letter of notification.…

Outcome: There were new standard operating procedures created to prevent this from happening again.

Issue: On 12/06/11 a VA employee found several printed patient orders in the lobby. These copies were mixed in with the suggestion cards located on the window ledge where the Medical Service Administrators (MSA) sit. This was discovered at 7:10 AM…

Outcome: The employee sent an email to a Supervisor asking her to inform the MSAs not to place any information etc, in the lobby until it is reviewed for personally identifiable information (PII) or protected health information (PHI).

Issue: A notebook with Microbiology result slips was found in old Emergency Room (ER) which was decommissioned upon new Emergency Department standing up. Space is limited access to VA Facilities management staff, VA Construction Contracting Staff, and VA Police. VA Police…

Outcome: Education, retrieval, and credit monitoring letters.

Issue: A medical resident's backpack was stolen out of his vehicle on December 3, 2011. In the backpack was a small notebook in which the resident kept a list of the patients he had treated for follow-up purposes. The notebook's loss…

Outcome: The medical resident whose notebook was lost in his stolen bag provided the Privacy Officer with the two other small notebooks he had. He stated he had no other Veteran information in his possession. He has been instructed that residents…

Issue: In the early evening hours of 11/22/11, Veteran discovered 2 manila folders labeled with Veterans' full names, full SSNs and protected health information (PHI) sitting unattended in a smoking shelter on VA property outside the Medical Center building. The Veteran…

Outcome: The employee who carried the files outside the building has repeated his VA Information Security and Privacy Training modules and been counseled by his Supervisor that his actions were not acceptable. A report of the incident is being provided to…

Issue: The Service Line Business Manager was requesting staff to provide details for Personal Identity Verification (PIV) sponsorship. This included the employees' name, full SSN, and date of birth. The Business Manager provided a fax number that was not correct. Staff…

Outcome: Contact was made with the Seattle company that had received the employees' information. Out of 122 recipients of the email that contained the incorrect fax number, 11 staff have been confirmed to have sent personal information to the incorrect number.…

Issue: Veteran A received a 6 page letter in the mail from our facility notifying him that he had been authorized to receive non-VA Purchased Care for a certain treatment and a 7th page was folded in the envelope with Veteran…

Outcome: The employee who made the error has been counseled to take more time when printing and mailing Veteran information back to back. The office Supervisor will be spending more time overseeing the process.