Northwest Network (VISN 20)

Issue: Veteran A received a lab results letter in the mail and Veteran B's two page lab results letter was folded with the first in the envelope. Veteran A called his VA clinic to report the error. Veteran A has destroyed…

Outcome: The VA clinic which made the mailing error is changing their process for printing and mailing the lag results letters to prevent confusion that could be causing this type of error. The employees have also been reminded of the need…

Issue: Veteran A received a lab results letter in the mail and Veteran B's two page lab results letter was folded with the first in the envelope. Veteran A called his VA clinic to report the error. He is mailing Veteran…

Outcome: The VA clinic which made the mailing error is changing their process for printing and mailing the lag results letters to prevent confusion that could be causing this type of error. The employees have also been reminded of the need…

Issue: A vulnerability was discovered on a shared listserv utilized by VA Puget Sound researchers, the Fred Hutchinson Cancer Research Center and possibly twenty-five other sites involved in Bone Marrow Transplant studies. An email/listserv was utilized by all twenty-five sites to…

Outcome: The Director's Office is convening an Administrative Investigation Board (AIB) to more fully investigate this incident. Training on privacy policies and procedures will be conducted in conjunction with the ISO and Research and Compliance Offices. Monitoring letters sent.…

Issue: VISTA record access logs show that a VA Nursing Assistant accessed a Veteran's record on 6 occasions this year while the Veteran was not an in-patient. This was found after the Privacy Officer was made aware that Supervisors were reviewing…

Outcome: The employee was advised that accessing the records was not appropriate. A summary memo documenting the violations was sent to the Chief of Human Resources to be reviewed for disciplinary action.

Issue: It appears that a VA employee accessed the medical record of a family member without a need to know on four different dates as listed below: NOV 08, 2011@08:38 SEP 27, 2011@10:41 JUL 27, 2011@15:05 JUL 07, 2011@07:43 Update: 11/15/11:…

Outcome: A memo documenting the Privacy Officer's Fact Finding has been sent to Human Resources for disciplinary action along with a copy of the Sensitive record access log and the employee's Privacy and Information Security Training reports.

Issue: A VA employee accessed an VBA employee's CPRS record twice on 08/25/11, obtained information and then shared that information with another VA employee who then reported it to the Chief of the section. The CPRS record contains the name, address,…

Outcome: Employee will be suspended w/o pay and has to take re-take Privacy Training

Issue: Veteran A called the Health Resource Center (HRC) to report that he received two statements through the mail for Veteran B. The VA facility listed on the statement is: Portland, OR. Veteran A returned the statements without its original envelope…

Outcome: The facility Enrollment Office reviewed and confirmed that information for Veteran A had been incorrectly entered as contact information for Veteran B. The error was quickly fixed in the Veteran's record based on documents that had been scanned into the…

Issue: Two letters from a provider were sent to a Patient A. One letter had the lab results for Patient A. Patient A also received the lab results for a Patient B. Patient A lives in a community residential housing unit.…

Outcome: The clinic manager stated that all letters mailed to patients will now be reviewed by two staff members to ensure that the contents of the mailings pertain to the individual to whom the envelope is addressed.

Issue: A patient called the Privacy Office to report having received another Veteran's cancer screening information. Full name and SSN were listed on the letter. Update: 10/25/11:The patient will be sent a letter offering credit protection services.…

Outcome: Retraining on privacy policy provided to sender. Credit monitoring letter was sent.

Issue: Veteran A received a prescription refill in the mail with additional pharmacy information printed included in the envelope. On one page, Veteran B's information printed under Veteran A's information. At first glance it appears the text on the page is…

Outcome: The printing error was able to be recreated. The occurrence of this error is expected to be rare because it requires to two print jobs to be sent to that printer from two separate users simultaneously. The staff sending the…