Northwest Network (VISN 20)

Issue: Mis mailing of information to a Veteran. Veteran received lab results that was not his own. Incident not reported in accordance with time frames due to misunderstanding/miscommunication by Contractor in accordance with the recently established BAA. Update: 02/09/11:The Veteran whose…

Outcome: Plan of corrective action in place.

Issue: A box of 50 to 75 Veterans Identification Cards (VIC) was discovered missing from the Enrollment Office. These cards were being held for homeless Veterans or Veterans whose cards were returned to the facility due to bad mailing addresses. The…

Outcome: Staff will maintain an electronic list of all cards printed and picked up from this point forward. The box of cards is now kept in a locked drawer in a locked office. 4 CM letters mailed on or will be…

Issue: Veteran went to Director's office to report that requested records were sent out in an envelope that was improperly sealed with a single piece of tape. The envelope appeared to have been tampered with and the bottom portion of the…

Outcome: CREDIT MONITORING LETTER SENT OUT

Issue: One of the Director's secretaries received a call from a business stating that they had received a faxed report that contained the names, SSN, appointment information, etc. for 30+ Veterans from our ENT clinic. The caller stated that he is…

Outcome: Investigation information being sent to Human Resources and employee's supervisor for appropriate action. Type of action taken is unknown to the Privacy Officer. Education training was done during the interview process by the Privacy Officer. Employee worked with physician the…

Issue: An employee's six-part (personnel) folder is missing, as well as his service card, which contains all identifiable information and employment information. Update: 01/22/11:Employee will receive a letter offering credit protection services since his full SSN and DOB are on these…

Outcome: LETTER SENT TO EMPLOYEE OUTLINING INCIDENT AND OFFERING CREDIT MOITORING. OFFICES WHERE THE INFORMATION WAS STORED HAVE BEEN NOTIFIED IN AN ATTEMPT TO LOCATE THE FILE.…

Issue: Records released to a family member without proper authorization Update: 01/20/11:Veteran will receive a letter offering credit protection services.…

Outcome: LETTER SENT OUT NOTIFYING VETERAN OF VIOLATION AND OFFERING CREDIT PROTECTION

Issue: On December 20, 2010, a Rx for Patient A was handed to Patient B. Patient B returned the sealed package unopened to the pharmacy, but he may have seen the name of the medication prescribed for Patient A. Update: 01/13/11:Veteran…

Outcome: Education provided

Issue: Clinical laboratory report of one veteran was mailed to another veteran by mistake. Name, SSN and PHI were released. Update: 01/11/11:Veteran will receive a letter offering credit protection services since his full SSN and DOB was exposed.…

Outcome: The ISO met with the staff and provided education

Issue: A veteran's PHI was released but had not been authorized for release. The info released included a medication list, Mental Health notes, surgery notes, suicide risk assessments, and other related notes. Update: 01/06/11:Veteran B will receive a notification letter.…

Outcome: This error was made by an experienced ROI clerk who has not had any mistakes reported in the past. Human Resources will be notified of this violation.