Northwest Network (VISN 20)

Issue: A patient had repeatedly made phone calls to a clerk to have team RN call her. The patient came in and saw her own PHI and contact information easily visible on a post-it note at the clerk's station and it…

Outcome: Education of employee and mailed notification letter.

Issue: On 05/20/11, The Pacific Medical representative and his associate came to the sterile processing department (SPD) supervisor's office to show her three invoices that needed to be paid for. He asked the employee to put in a purchase order (PO)…

Outcome: Provided education to VA staff that printed labels with patients SSN and name to ensure future events do not occur. Policies are being reviewed to assess the way in which vendors are accessing the hospital premises and patient sensitive information.

Issue: On May 2, 2011, a Release Of Information (ROI) Technician provided a CD to Patient A, whichcontained two pages of information on Patient B. Patient B brought the CD in and the Privacy Officer was notified. The original CD was…

Outcome: PO educated staff, retrieved CD and notified VHA. Notification letter sent.…

Issue: A Veteran received two letters addressed to him, one contained his filled out form requesting more information. The second contained another Veteran's filled out form requesting more information. The Veteran returned information to Information Security Officer (ISO) office. Update: 05/12/11:The…

Outcome: letter sentreducation conducted

Issue: Veteran A's means test was sent to Veteran B. Update: 05/10/11:Veteran B will be sent a letter offering credit protection services, due to full name and full SSN being exposed.…

Outcome: Education was provided to staff involved.

Issue: Medical information was released to a family member without the proper documentation. Update: 05/11/11:Veteran A will be sent a letter offering credit protection services.…

Outcome: PO CONTACTED EMPLOYEE AND NOTIFIED THEM OF THE INCIDENT. WENT OVER THE PROPER PROCEDURE WITH THEM AND FOUND THAT THEY WERE AWARE OF THE STEPS NEEDED TO COMPLETE A THIRD PARTY RELEASE. IT WAS FOUND THAT THE EMPLOYEE ASSUMED AN…

Issue: A VA Chaplain conducted Bible study activities with three VA Employee's during work hours and then entered these Bible studies encounters into their VA electronic employee health records. This activity is outside of the Chaplains official duties. The Chaplain does…

Outcome: Counseling to employee by immediate supervisor.

Issue: Patient A was given the wrong medication (for Patient B). Update: 05/04/11:Patient B will be sent a letter offering credit protection services.…

Outcome: Retrieval and education to staff.

Issue: A spreadsheet containing medical information for 5 Veterans was found by a Veteran on the pavement just outside the back door of the medical center. The 3 page spreadsheet indicates it is intended for use by Physicians as a quick…

Outcome: The provider who printed this copy of the spreadsheet could not be determined. The attending over that specialty office was to advise all who may be using this spreadsheet that this event had occurred and these documents must be disposed…

Issue: On Wednesday, April 27, 2011, A Puget Sound police officer lost his issued pocket size notebook containing private patient Personally Identifiable Information (PII) as well as officer notes for police reports. No other information is available at this time. Update:…

Outcome: Provided privacy training and credit monitoring letter sent.