Northwest Network (VISN 20)

Issue: A VA doctor was taking medical records home. The records were left in a brief case in his privately owned vehicle (POV). The POV was broken into and brief case was stolen. The brief case has been recovered, but it…

Outcome: EMPLOYEE WAS PUT ON AN ACTION PLAN. PERT OF THE PLAN INCLUDED REVIEWING CURRENT PRIVACY TRAINING AND REVIEWING THE VA RULES OF BEHAVIOR. THE ACTION PLAN WILL BE ON GOING UNTIL COMPLETE.…

Issue: The Privacy Officer (PO) notified by VARO Supervisor that while employee was interviewing a Veteran at the V A Puget Sound Health Care Center he discovered his Veteran client appointment list was missing. The list contained the names and social…

Outcome: Employee that lost Veteran contact list will be retrained as to the proper procedures for safeguarding III and IIHI. Employee will be asked to minimize the amount of paper documents when interviewing Veterans for VBA benefits when offsite. Some of…

Issue: Veteran A received Veteran B's lab letter with the letter he received. The Veteran will be mailing the letter back to the facility. Update: 08/21/12:Veteran B will be sent a notification letter.…

Outcome: The office which mailed the letter has been made aware of the mistake and the staff in the clinic are being informed to prevent this from occurring again.

Issue: Veteran A reported to the local Patient Advocate he received mail for Veteran B at his address. The Veterans addresses are correct in the record and an appointment for Veteran A was scheduled minutes before an appointment for Veteran B…

Outcome: The employees who gave the wrong appointment letter to the Veteran in the clinic are aware of the error and will work to prevent this error from being repeated.

Issue: A VA provider wrote a letter to Veteran A. This was sent to Veteran B. Veteran B brought in the letter for Veteran A to the Veteran's Service Office. The Veteran's Service Office in turn forwarded this to the Privacy…

Outcome: Have met with staff & discussed the importance of ensuring patient confidentiality when mailing the letters to the veterans.

Issue: Patient A was recently discharged from the domiciliary. When discharged, he was mistakenly given a bag of medications that belonged to Patient B. Both patients have the same last name. The bag of medications were brought in by Patient B…

Outcome: Pharmacy has retrained all staff to double-check SSN and names prior to releasing any items upon discharge, as there are instances when you may have more than one individual with the same name admitted to the same ward.

Issue: Veteran A requested her records on CD from the Portland VA Medical Center Release of Information Office but was mistakenly given Veteran Bs records on CD. The CD contained 64 pages including Veteran B's full name, address, full SSN, medication…

Outcome: The office that created the CD has discussed the process in which allowed the incorrect information to be burned to the CD disclosed. The employees have been instructed to use a separate process to prevent this error from being repeated.

Issue: While leaving a clinic appointment on July 12, 2012 the clinic staff scheduled a follow-up appointment for Aug 9, 2012 and printed an gave the Veteran an appointment letter with the pending appointment date and time. The employee who created…

Outcome: The employees who made the mistake and gave the letter to the wrong Veteran when both were at the clinic have been advised by their supervisor to take greater precautions before handing printed material to the Veterans or mailing it.

Issue: An Imaging department supervisor reported to the facility Privacy Officer that she heard a complaint about 2 CDs containing Veteran patient information that had been left by a Medical Resident in an auditorium at the Affiliate Medical University next to…

Outcome: Our Facility Privacy Officer is working with our Imaging and Operative Care departments to have our providers reminded that our Veterans data must remain within the facility where it is secure.

Issue: Veteran A reported through the national VA Patient Advocate's office stating: "I received health items (catheters) in the mail that were supposed to go to another veteran with the same first and last name. What do I do?" There are…

Outcome: The Pharmacy office mailing packages is working with the mail room handling their packages to ensure addresses are not changed when supplies are put in new containers for shipping.