Northwest Network (VISN 20)

Issue: A VA nurse called the Wal-Mart pharmacy to get a fax number to send a prescription to. The wrong fax number was given to the nurse. The nurse faxed the prescription to the number provided. The nurse received a call…

Outcome: Sent out credit monitoring letter. There is no other action because the error originated outside of the facility.…

Issue: An employee accessed a veterans medical record under the auspice of a friend. She contacted several VA employees regarding resources for the veteran. The veteran was not being seen by the clinic the employee worked in and it was not…

Outcome: Employee given a letter of counseling and scheduled to attend a special Privacy Training for all nurses in January 2013

Issue: A Veteran discharged from a VA inpatient ward at noon on October 31, 2012 was given a copy of his discharge note and a one page medication list for another Veteran was picked up off the printer and given to…

Outcome: The supervisor on the the inpatient Ward where this occurred has been notified of the mistake and was asked to remind all staff to review documents before handing them over to patients.

Issue: A Veteran issued a complaint that a VA nurse contacted his old caregiver point of contact and disclosed health care appointment information. Update: 10/30/12:The Veteran entered into a caregiver certification program support agreement with caregiver A on 07/02/12. On 07/10/12,…

Outcome: New contact information has been updated in Veterans record. Employee has been counseled. Notification letter completed.…

Issue: A Veteran met with and notified the facility Privacy Officer (PO) that the Release of Information (ROI) office responded to a medical records request authorizing the disclosure of Urinary Analysis (UA) drug screen results to an attorney and an additional…

Outcome: The employee who disclosed the information is aware of the complaint by the Veteran and is aware of the need to clearly understand what documents are being authorized for release. Since the incident the employee has taken a position in…

Issue: This is the second incident where a Bellevue Valor Clinic (CBOC) employee mailed the Patients Laboratory Correspondence letter with the laboratory results of Veteran A to Veteran B. Veteran B brought the lab results of Veteran A to the Bellevue…

Outcome: The staff member responsible for this incident has been counseled and has been advised to follow procedures already in place to avoid mismailing of protected health information. Valor senior management is apprised of the incident and will provide additional guidance…

Issue: A new VA employee received lab results in the mail from a blood test done for employee health purposes. In the envelope with his results were results for another employee. The Employee brought the documents to the Privacy Officer today.…

Outcome: The office that mailed the letters are aware of the mistake and is making greater efforts to check their outgoing mail to prevent this from occurring again.

Issue: Veteran A requested a copy of a note from his VA Medical Record from a clinic clerk but the note provided was not his. The Veteran did not realize this until he presented it to a Veteran Service Officer he…

Outcome: We believe the mistake was made because the other Veteran shares your same last name and your social security numbers end with similar digits. The employees working at the clinic where the note was printed have been notified of the…

Issue: A Bellevue Valor Clinic employee mailed the Patients laboratory Correspondence letter with the laboratory results of Veteran A to Veteran B. Veteran B brought the lab results of Veteran A to the Bellevue Valor Clinic, so that clinic staff were…

Outcome: Laboratory assistant responsible for incident was counseled and informed that they must follow protocol in regards to mailing protected health information, specifically laboratory results. Valor senior management is apprised of the incident and will also ensure that safeguards are in…

Issue: A Veteran has reported that an unknown VA employee contacted his brother without authorization while he was an inpatient around the date of 10/04/12 and disclosed that the Veteran was an inpatient and upset with his brother. The Veteran says…

Outcome: A review of the Veteran\xe2\x80\x99s records shows his brother is listed as a Next-of-kin contact but there are no release authorizations on file permitting information to be disclosed to him. We do have an Advance Directive and Durable Power of…