Northwest Network (VISN 20)

Issue: Employee A has reviewed the access log to her VA medical record and noted that a co-worker has accessed her record without her authorization or need to know. She reports that this same co-worker has accessed Employee B's medical record…

Outcome: The employee who accessed the records has been counseled that she did not have a need to know in these instances. The employee signed a memo acknowledging that she received this counsel from the Privacy Officer and her supervisor. The…

Issue: Veteran A called after hours on 04/05/11 and left a voicemail regarding having received medical documents on Veteran B. The Privacy Officer (PO) called Veteran A back on 04/06/11 but he was sleeping and wasn't able to get much information…

Outcome: PO have met with the supervisor of the department and have requested that they use windowed envelopes for all mailing

Issue: A Veteran came to the Privacy Officer to report that two pages of Veteran B's information were included in the envelope in which he received his medication via UPS. The Veteran showed the entire package to the Privacy Officer and…

Outcome: The Pharmacy supervisor is to instruct all staff on checking outgoing documents to be sure all education pages are present and no additional pages from other Veteran's printouts are sent to the incorrect Veteran.

Issue: Veteran A received Veteran B's and Veteran C's medications in the mail. Veteran A returned the medications and reported event to Privacy Officer and Patient Safety. Update: 04/01/11:Veterans B and C will receive a letter of notification.…

Outcome: LETTER SENT TO VETERANS. STAFF WAS GIVEN TRAINING TO STOP INCIDENTS LIKE THIS FROM HAPPENING.

Issue: Veteran B was discharged from a ward and accidentally given Veteran A's document (VA Form 119) which included Veteran A's full name, social security number, address, and phone number. Veteran B noticed that the paper had Veteran A's name on…

Outcome: Provided ward education.

Issue: VA mis-mailed Veteran A's appointment schedule letter to Veteran B. Veteran B came into the VA with 2 appointment letters thinking that he had an appointment and he checked in with the appointment desk clerk who looked him up in…

Outcome: Spoke to mail room clerk. Made him aware of the incident... automated folding/stuffing machine has sensory alarms that are suppose to detect errors such as this when two forms get pulled instead of one... but this one time the machine…

Issue: Three (3) DICOM imaging DVDs (X-rays) were hand carried to the front desk of a Portland VA CBOC and turned over to VA staff. The Veteran presenting them indicated the DVDs had been mailed to him by mistake and he…

Outcome: CDs were retrieved. Imaging staff will be educated about the importance of verifying the addresses on mail before being sent.

Issue: A volunteer took home a patient transport trip ticket for three days. Update: 03/28/11:Volunteer got blood on herself from the Veteran which made her concerned and she kept the tick.03/29/11:One Veteran will receive a letter offering credit protection services.…

Outcome: The volunteer who held the information was counseled not to remove any information from the facility and to notify her supervisor, employee health department, or ED attending immediately if she believes she may have had contact with fluids.

Issue: A fecal occult blood test (guiac) card was sent to the wrong Veteran. Update: 03/22/11:The information also included the other Veteran's full SSN. The Veteran will be sent a letter offering credit protection services.…

Outcome: Education and training was provided.

Issue: A letter was sent to one Veteran (Veteran A) and a second Veteran's (Veteran B) letter was attached to Veteran A's letter. Update: 03/22/11:Included on the letter was Veteran B's name, address, and lab results. Veteran B will be sent…

Outcome: The PO met with the employee and discussed the incident. Together we developed a plan to have the clerk on the team go through the information to be placed in the envelope prior to sealing it to ensure that the…