Northwest Network (VISN 20)

Issue: Upon discharge from the Emergency Department (ED), a physician placed Patient B's label on Patient A's paperwork. Both patients had been treated in the ED. The label contained Patient B's name, SSN, and date of birth. The ED staff attempted…

Outcome: All staff will be re-trained on proper procedures for disseminating discharge documentation. Clerks will provide documents to patients upon discharge rather than clinicians, as clinical staff (residents) rotate and varies from day-to-day.

Issue: A Veteran, who enrolled for health care services at American Lake hopsital today, between 10:30 a.m. and 11:00 a.m. stated that he was serviced by a clerk (full description given). Veteran stated that this gentleman asked for a copy of…

Outcome: Employee has been counseled and will receive ongoing training and mentoring on safeguarding our Veterans medical and personal information. privacy has recommended that Service Line ensure that employee is aware of SOP for registering new patients, and that safeguarding their…

Issue: Veteran A called to report that he received a package of medications which belong to Veteran B. Veterran A will be in Walla Walla on Monday and will bring the package to the Pharmacy at that time. Update: 06/18/12:Veteran B…

Outcome: Privacy Officer and Supervisor of Pharmacy met to discuss process for a second review of medications being sent out of the pharmacy.

Issue: Veteran A received Veteran B's lab results letter in the mail. It was dated 05/25/12.. Veteran A carried the letter to the facility and gave it to lab staff today 06/07/12. The letter contained Veteran B's name, address and lab…

Outcome: The clinic employees where the mailing error was made are aware of the error and their clinic manager has spoken to them about the need to pay attention to detail so mismailing does not occurr.

Issue: A Veteran had an appointment at the North Seattle VA Clinic on 6/4/12 at 3:15 pm. While sitting in the exam room with the Physician Assistant (PA) prior to her exam, the Veteran was able to write down the name,…

Outcome: Provider will be mentored and advised regarding privacy and information security awareness. Compliance Officer for Valor Clinic has been notified of the breach and will counsel provider regarding the seriousness of the breach and corrective actions to prevent such an…

Issue: A VA provider requesting a Veterans record from a non-VA hospital transposed 2 digits of the hospitals fax number when the release form was faxed out on 05/25/12. The fax was received at a residence. The recipient saw the name…

Outcome: The employee who recorded the fax number incorrectly is aware of the error and the consequences of seemingly simple mistakes. They will be making an earnest effort to verify fax numbers before use in the future.

Issue: Veteran A received a letter intended for Veteran B in the mail. The letter contained Veteran B's name, address, full SSN and protected health information (PHI), including the diagnosis and lab results. Update: 05/30/12:Veteran B will be sent a letter…

Outcome: The Privacy Officer spoke with the Community Based Outpatient Clinic (CBOC) staff and suggested that they have a double check process for all outgoing mail.

Issue: Veteran A received Veteran B's information due to the incorrect address information being in CPRS. Veteran B's name, address, date of birth, full SSN, and diagnosis were disclosed. Update: 05/25/12:Veteran B will be sent a letter offering credit protection services…

Outcome: Staff has been retrained and reminded of the policies and procedures in regards to adding data to medical records.

Issue: A VA Employee/Veteran was arrested this week and it was in the local paper. The Privacy Officer (PO) ran a sensitive access report and will investigate why 8 staff had accessed the record this week. Will be questioning employees if…

Outcome: HR/Supervisors made aware of three violations and copies of findings. HR/Supervisor to determine potential further action against three employees. PO also requested the three employees retake the Privacy & HIPAA Training FY 12.

Issue: A Veteran received their lab information as well as a letter and lab information on another Veteran. It appears that a VA employee may have transposed some numbers as both veteran's last 4 of their social security number have just…

Outcome: PO training, and discussion with the treatment team.