VA Southwest Health Care Network (VISN 18)

Report ID: PSETS0000086336, U.S. Department of Veterans Affairs

Reported Entity: VISN 18 Phoenix, AZ

Issue:

Today, 3/4/2013, PO returns Veteran phone message. Veteran indicates he received a follow-up appointment response letter from his PCP with instructions for his next appointment. Underneath his materials, were the same types of letters for 12 other Veterans. The Veteran thought that the size of the package was due to his research participation but found other materials instead. Did not ask reporter to review materials further, to minimize other Veteran exposure. Asked reporter to aid in recovery of documents to protect Veterans and assist in their care. Agreed, will bring documents to his appointment here tomorrow. PO will meet him to recover documents then. Additional notification and investigation to ensue. Update: 3/13/12:The PO received 13 recovered letters from Veteran who reported incident today. Delay in escalating event was due to recipient of the envelope which was suspicious smelling of waste materials. VA Police took original documents into custody as bio-hazardous waste report.Therefore 12 Veterans will a notification letter.

Outcome:

The provider could not identify who in her PACT actually sent the letters to multiple Veterans in one envelope. She then conducted an in-service and one-on-one counseling session with all of her staff, showing them the Privacy Officer memo on mail outs. The provider also obtained a new printer in her office for document control which is accessible to only herself and her nurse. Corrective actions concluded.