Northwest Network (VISN 20)

Issue: Veteran A sent the prescriptions and a letter stating that he had received someone elses (Veteran B) filled out prescription blanks to be filled at a pharmacy of the patients choice. In the letter Veteran A described this is the…

Outcome: After investigation it could not be determined exactly which clerk input the wrong address. I will be conducting a targeted educational presentation at the next quarterly HAS department mini-camp specifically regarding the necessity to always double check Names, SSN and…

Issue: Veteran A received 2 medications intended fo Veteran B. Veteran A had an appointment with home based primary care and at that time reported having received the medication of Veteran B. They both reside in the same apartment complex and…

Outcome: Sent a HIPAA letter notifying veteran of Postal service error. Will attempt to alert local post office of the mistake and counsel the postal manager to be aware of the possibility of future issues.

Issue: Veteran A's medical records were given to Veteran B. Update: 07/26/12:Veteran A will receive a letter offering credit protection services.…

Outcome: SENT OUT CREDIT MONITORING LETTER. INFORMED SUPERVISOR AND EMPLOYEE. REFRESHED TRAINING.…

Issue: Veteran A called the Portland VAMC and stated he received a letter from his PCP's office, dated 7/18/2012, reporting recent lab results. He turned the page over and found Veteran Bs medical record information on the back side of the…

Outcome: The employee who mailed the document could not be determined. The staff at the clinic where it was mailed from have been made aware of the printing mistake and are trying to identify processing issues that may have permitted this…

Issue: A nurse at VA Puget Sound was concerned that former co-workers had accessed her record based on comments that some of them had made to her. She requested a copy of her Sensitive Patient Access Report from the Privacy Officer…

Outcome: The employee who had accessed thirty-six other employees medical records has been dis-usered and presently being investigated and sanctioned by the Service Line and by HR. The outcome has yet to be determined. This employee will be terminated from VA…

Issue: Veteran A received Veteran B's lab results letter in the envelope with his own. He called the VA Lab and told them he was going to mail Veteran B's documents back to the facility. They were received and presented to…

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: A VA Patient returned another Patient's ultra-sound results from the clinic to Release of Information (ROI) clerk, handwritten "This was sent to me by mistake. This is not my x-ray report." Update: 07/13/12:Patient B will be sent a notification letter.…

Outcome: The Veteran immediately returned the other Veteran's record and credit monitoring was sent.

Issue: Veteran A brought lab results and provider letters for Veterans B and C with him to his clinic appointment on July 11, 2012. A package with medication intended for Veteran B was included with the letters but the package was…

Outcome: The mailing error occurred because another Veterans address change had been recorded in your record. The employees mailing these items believed they had the correct address. Arrangements were made for the Pharmacy to re-mail the medication that day. The office…

Issue: Patient A received his own discharge instructions, but with the patient identification sticker for Patient B. The patient ID sticker has full name, full SSN, full DoB. Update: 07/11/12:Patient B will be sent a letter offering credit protection services.…

Outcome: Nurse responsible for the mis-handling of the patient identification label has been retrained on the proper procedures for discharging patients. Clerks are responsible for this function, so as to ensure that minor errors such as this one does not occur…

Issue: On July 6, 2012 a VA Employee Veteran who is treated at our facility received a letter from the Portland VA Eye clinic that was postmarked July 2, 2012. The street address was hand-written on the envelope and the house…

Outcome: The Privacy Officer has spoken to the employee who handled the letter when it was sent so they are aware of the error and can avoid similar mistakes in the future.