Northwest Network (VISN 20)

Issue: There was a mismailing of medication(s) due to two Patients with the same last and first name. Update: 02/13/13:Patient A and B will be sent a notification letter.…

Outcome: HIPAA Notification letter mailed. Staff reeducated on Patient Identification Authentication processes and safeguards.…

Issue: A Veteran requested a return to work note from the provider. Upon reviewing the document several days later the Veteran realized they were given the wrong letter. The letter was returned to the clinic and the correct letter then given…

Outcome: Staff in the clinic were reminded to validate documents before giving them to Veterans, and encouraged to document such letters in CPRS and have the Veteran get the copy through the ROI office.

Issue: A VA Employee accessed the electronic record of a family member that they have a restraining order against. Update: 02/13/13:Veteran A will be sent a letter offering credit protection services.…

Outcome: Notification letter sent out. Notified Supervisor. Supervisor notified HR.…

Issue: Veteran A was contacted by Veteran B who explained he had received an envelope from the Portland VA Medical Center containing his own paperwork as well as a Health Benefits form (VA 10-10EZ) that had been completed and signed for…

Outcome: NA

Issue: A facility Privacy Officer (PO) walked past a vehicle parked on the VA campus and noticed a stack of medical records in the front passenger seat of a car. The VA Police assisted in identifying the owner of the vehicle…

Outcome: The provider who placed the records in the car did not intend to do so and he has been directed by his supervisor and the Privacy Officer as to the need to be careful while handling documents to ensure they…

Issue: A staff member left a Veteran's contact coversheet in a restroom near the Social Work office. The sheet was found in the restroom and given to the service within 30-60 minutes. Update: 02/05/13:The Veteran will receive a notification letter.…

Outcome: Employee has been counseled, accepted responsibility and will retake Privacy training.

Issue: An appointment letter was sent to Veteran A that had the name and SSN of Veteran B. The address in the system for both Veterans A and B is the same. The address located in both records belongs to Veteran…

Outcome: Informed the Regional Office of the error. Fixed the error in our system. Mailed out credit monitoring letter.…

Issue: A lab report for Veteran A was sent to Veteran B along with Veteran B's lab report. Update: 01/30/13:Veteran A will be sent a letter offering credit protection services due to full name and full SSN being disclosed.…

Outcome: Sent out credit monitoring letter. PO informed employee and supervisor of the issue. PO talked with staff responsible for sending out the notifications and informed them of the importance of double checking things they mail out.…

Issue: A man without a photo ID was treated in the VA Emergency Department and his treatment was documented in the medical record of a Veteran with the same name on two occasions in December 2012. The man was not given…

Outcome: NA

Issue: This issue was first identified by Valor Healthcare, Inc. on 01/08/13 at 12:10 PM after Veteran A's wife contacted the RN Administrator at the Federal Way Community Based Outpatient Clinic (CBOC) and informed her that she discovered that her husband…

Outcome: Staff at CBOC were re-educated as to the proper procedures for distributing prescriptions to patients, and ensuring that mis-handling did not occur.