Northwest Network (VISN 20)

Issue: Veteran A received Veteran B's VA printout of his Request for Outpatient Services (ROS). The Veteran noticed the mis-mailing error and returned the mis-mailed paperwork via mail to the Spokane VAMC which was forwarded internally to the Privacy Officer (PO).…

Outcome: Counseled employee to double check accuracy prior to mailing any correspondence letters also gave awareness training to other pertinent staff.

Issue: A clinic schedule was laying on the clinic front desk. A patient laid down some personal papers while interacting with the clerk. It is unknown if the patient picked up the pile of papers or the clerk handed them to…

Outcome: Education provided.

Issue: A Veteran received printed lab results dated March 3, 2011 in the mail and another Veteran's one page lab results report folded behind his. The Veteran did not notice the second page until the next day. He reported the identity…

Outcome: Employees in the clinic advised of the error and the clinic manager is reinforcing the need to check all pages of outgoing mail to verify they belong to the recipient.

Issue: An Information Technology (IT) employee found an electrocardiogram (ECG) report for Patient A on the canteen floor on March 14, 2011 at approximately 7:10 AM. The IT employee has the report in their office. The patient is in the Surgical…

Outcome: Education was provided.

Issue: The librarian found Veteran medical records on top of trash receptacle in the Canteen. Update: 03/15/11:The investigation revealed that an employee left the document in the Canteen. It contained the full name, SSN, and medical information of the Veteran. The…

Outcome: Education was provided.

Issue: Appt letters from 3 veterans was stuffed into the envelop of another veteran's appt letter. The mail sorter equipment will stuff envelope with more than one letter. Update: 02/24/11:Three (3) Veterans will receive a letter of notification.…

Outcome: Malfunction mail sorter. Contractor notified by Chief of HIMS to repair. There is a contract being made to obtain new equipment since this is a recurring issue.…

Issue: VETERAN RECIEVED A CD CONTAINING THEIR MEDICAL RECORDS AND MEDICAL RECORDS OF ANOTHER VETERAN Update: 02/24/11:Veteran will receive a letter offering credit protection services since their full SSN was exposed.…

Outcome: Staff was re-trained.

Issue: Appt letters were printed on 2-11-2011 and on 2-17-2011 the envelope to return to VA was postmarked 2-17-2011. Veteran returned the 3 additional letters to the clinic team. I was then notified. We have had problems in the past with…

Outcome: Mail Sorter Machine puts more than one letter into an envelope. The Chief of HIMS had already contacted the agency to repair the machine and the Chief is in the process of getting a contract to get new equipment. Notification…

Issue: Person called to say that a Veteran (Veteran A) had received an appointment letter and there were other letters inside (belonging to Veteran B). The employee did not get the person call only a veteran whose letter did not belong…

Outcome: Sorter letter machine company was contacted to come fix the sorter as it is stuffing envelope with more than one letter. This particular case had only one additional letter. Notification letter sent to veteran 2-16-2011.…

Issue: On 2/15/2011, around 0800 hours, Health Plan Management/ Fee Services Supervisor called to report a missing folder containing CPRS records of approximately 37 Veterans from Gastroenterology Department. Incident occurred at Building 85/ Room 215 between 2/10/2011 1600 hours to 2/14/2011…

Outcome: HPM Service Line is conducting additional training and awarenss of proper procuderes for storing sensitive files, and have provided a locking file cabinet for non-business hour storage of sensitive files. In addition, the specific areas of the Facility have been…