Northwest Network (VISN 20)

Issue: A local VA Patient Advocate received a report forwarded from VA Central Office regarding a Veteran A who received a lab results letter for Veteran B with a letter that was sent to him. Veteran B also appears to be…

Outcome: The office who mis-mailed this information has been instructed by their supervisor to review the contents of outgoing mail to ensure it is being sent to the correct Veteran.

Issue: A document containing Personally Identifiable Information (PII) was found on the ground outside the medical center. The document conatined the patient's name, address, full SSN, date of birth and medical diagnosis. Update: 08/30/11:Veteran A will be sent a letter offering…

Outcome: INFORMATION WAS RECOVERED AND CREDIT MONITORING LETTER WAS SENT OUT.

Issue: A non-VA form completed by a VA Provider was mistakenly mailed to the incorrect Veteran. Veteran A, who received the form completed for Veteran B, discovered it in his mail over the weekend and promptly contacted the facility's Release of…

Outcome: The employee who made the mailing mistake is aware of the error and has been counseled by his supervisor to take more time to check the content of outgoing mail.

Issue: Employee A authorized Human Resource (HR) Department to release their personnel record to their attorney. In the process, Employee A's spouse's (Employee B) personnel records were also released. Employee B is also a VA employee. The HR record went to…

Outcome: Human Resources had already started implementation of process changes at the time of our meeting with the employee. HR is being notified of the need for action on releasing the information without validating each page that was being released prior…

Issue: An Audiology Clinic appointment letter was given to Veteran A by the clinic scheduler. Veteran A brought it back to the Audiology Clinic after realizing it was incorrect on 08/18/11 at approximately 4:00 PM. The letter was meant for Veteran…

Outcome: The clinic clerk was educated regarding the best practices for ensuring that patients only receive their own appointment and medical information. Clerks will now double-check and verify that they are providing the correct information to the right individual.

Issue: A desk pulled out of office to sidewalk. The desk had information on it that should have been secured in a drawer. Update: 08/05/11:Two (2) Veterans will be sent letters offering credit protection services, due to full name and full…

Outcome: Employee and supervisor discussed breach. Appointment notice left in envelope on desk did not contain SSN, just name and appointment type (MOVE). Envelope retrieved immediately. Notification letter sent but probably no credit monitoring letter is necessary.…

Issue: On 08/03/11, the Privacy Officer (PO) was notified that a family member was sent and received the personal office items of a deceased employee. The family member contacted Puget Sound and was directed to return the documents which she immediately…

Outcome: Informed Service Line to double check items prior to mailing. Credit monitoring letters have been sent.…

Issue: An ongoing VA OIG criminal investigation being coordinated with local law enforcement produced one page of a VISTA Inpatient list printed on 04/20/11 at 7:32 AM. It was found in a box of the suspects belongings turned over to law…

Outcome: Notification letters for this incident were sent in the outgoing mail Oct 6, 2011. 5 to Next of Kin, 24 directly to Veterans. The VA Office from which the document was taken is now a controlled space where only authorized…

Issue: On 06/24/11, the husband of Patient A phoned the outpatient pharmacy to report his wife had received medication for Patient B in error. Patient Bs medication was received in the same mail package mixed in with medication for Patient A.…

Outcome: The employee's supervisor stated, "After completing fact-finding with the employee involved, it was determined the standard operating procedures were not followed and the employee was counseled."

Issue: During the course of an external facility investigation, it was discovered that a VA employee inappropriately released the records of 2 Veterans involved in the investigation to opposing counsel. This report is currently under investigation. Update: 06/03/2011:Veteran A and B…

Outcome: PO provided educational training, retrieval, and monitoring letters.…