Northwest Network (VISN 20)

Issue: Veteran A's labs included full SSN were included in Veteran B's records and were sent to Veteran B. Update: 07/10/12:Veteran A will be sent a letter offering credit protection services due to full name and full SSN being disclosed.…

Outcome: Credit monitoring letter sent out. Supervisor and employee were notified. Training was reviewed.…

Issue: A VA employee accessed their eOPF files on Friday, July 6th and noticed that the Security Background check coversheet containing the Name and SSN of another employee were commingled with their personnel information. The employee immediately contacted their supervisor, who…

Outcome: Contacted VA contractor ANACOMP in Chantilly, VA of the scanning error in eOPF. ANACOMP scans 500,000 documents per day for the VA.

Issue: Data collected on one VA Research subject screening form containing protected health information (PHI) was disclosed to a non-VA database for the study before authorization had been obtained from the subject to use or disclose his information. This disclosure occurred…

Outcome: The data entered into the database was removed by the University.

Issue: Veteran A was able to view the protected health information (PHI) of Veteran B on the computer monitor as the nurse did not lock her computer when leaving the exam room. The name, DOB, SSN and medical condition was clearly…

Outcome: Nurse responsible for this breach has been counseled, retrained and reprimanded per her supervisor. The Service Line Leader is also going to have a private conference with this individual, as this type of incident could have been prevented. The individual…

Issue: Two VA employees have been identified as accessing the VA Medical Record of a Veteran without a need to know in order to perform their duties. The Veteran is currently in a high profile local news story. The employees supervisors…

Outcome: The employees involved have been counseled by the Privacy Officer that the access violated Privacy laws and fact finding memos have been submitted to Human Resources for review.

Issue: Veteran A received Veteran B's laboratory results in the mail. Veteran A hand-carried the laboratory results back to the Community Based Outpatient Clinic (CBOC) upon discovering that he was mailed the incorrect laboratory results. Veteran A only had laboratory results…

Outcome: Staff has been retrained on the proper procedures for verifying address and contact information prior to releasing or sending documentation to Veterans. One clerk will be responsible for the mailing of lab results rather than three clerks, in order to…

Issue: Veteran A received the medical records of Veteran B from the Release of Information (ROI) Office. As soon as Veteran A realized they were not his records, he returned to the VA to report and hand over the records. Update:…

Outcome: Chief of HIMs and ROI clerk investigated how this could have occurred and will be more vigilant in mailing correct patient information

Issue: A social worker, who was interviewing for a new social work position, looked in the medical record of a Veteran who applied for the position. Update: 07/02/12:Veteran B will be sent a letter offering credit protection services due to full…

Outcome: Employee was reprimanded and a letter counseling placed in her personnel file.

Issue: Veteran A received a copy of his Progress Notes one week after his last VA appointment. The Progress Notes were ten (10) pages in length; however, pages 7-11 are pertaining to Veteran B. Veteran A brought the Progress Notes back…

Outcome: Chief of HIMS and medical records staff are auditing both of the affected Veteran's records to ensure that there isn't any further "co-mingling" of patient progress notes from their PCP. The PCP may have mistakenly added the notes of Patient…

Issue: A deceased Veteran's widow came to the Release of Information (ROI) Office at the Portland VAMC to request copies of the medical records that had been disclosed to her husbands father. Upon review of the fathers FOIA request dated 12/09/11,…

Outcome: Records releases involving 38 USC 7332 information will be discussed regarding the appropriatness of disclsoure of this information before permitting full disclosure.