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This database was last updated in December 2015 ago and should only be used as a historical snapshot. More recent data on breaches affecting 500 or more people is available at the U.S. Department of Health and Human Services’ Breach Portal.
VA Health Care Upstate New York (VISN 2)
Mentioned in a privacy incident report created by the U.S. Department of Veterans Affairs on January 3, 2012. Also cited in 132 other reports.
Report ID: SPE000000070283, U.S. Department of Veterans Affairs
Reported Entity: VISN 02 Syracuse, NY
Issue:
Emergency Department Nurse Manager reported that Patient A had received Patient B's discharge instructions in error. The Nurse Manager reported that the Emergency Room Department (ED)attending physician discharging Patient A, completed the discharge instruction sheet for Patient A with Patient B's identification label on it (name, SSN, date of birth) and gave it to Patient A. The Nurse Manager identified the error later that afternoon and contacted Patient A to notify him of the error. She was able to notify Patient A's daughter who was caring for him and confirmed receipt of Patient B's identifiable information and the correct discharge information for Patient B. The Nurse Manager advised Patient A's daughter of the need to destroy Patient B's identifiable information of which the daughter confirmed that she destroyed Patient B's information by cutting it up and burning it. The Nurse Manager will follow up to ensure correction of the Discharge Instructions to present Patient A's identifiable label and send to HIMS for inclusion in Patient A's medical record. Patient B ended up being admitted from the ED so did not receive any discharge instructions. In addition, the attending physician was notified of the error and the required protocol to confirm the patient's identification before releasing the discharge instructions. The Nurse Manager would also like to purse transition documentation of the discharge instructions as a long term solution to prevent future errors and will be discussing further with HIMS. Update: 01/04/12:Patient B will be sent a letter offering credit protection services due to full name and full SSN being exposed.
Outcome:
The attending physician was notified of the error by the nurse manager and Chief of ED and was re-educated on the required protocol to confirm the patient's identification before releasing the discharge instructions.