VA Health Care Upstate New York (VISN 2)

Report ID: PSETS0000086997, U.S. Department of Veterans Affairs

Reported Entity: VISN 02 Syracuse, NY

Issue:

Patient A reported that she received Patient B's letter regarding thyroid sonogram results when receiving her own letter regarding testing results from the Women's Health Clinic. Patient A reported to the Administrative Officer (AO) for Primary Care that Patient B's thyroid test results were stapled to her test results when receiving them in the mail. This resulted in Patient B's name, address, and diagnostic testing information being inappropriately disclosed to Patient A. The AO reported that Patient A agreed to mail back Patient B's test results to the VA so they could be properly destroyed. The AO will also mail a new copy of the test results to Patient B. After further review, it was determined that patient letters with test results were printed on the same day by the provider, therefore making it likely that they were mistaken by one of the clerical staff as one letter and identifiers on the reports not confirmed before mailed out to Patient A, resulting in the error. The AO will re-educate the staff on the requirement to check patient identifiers before mailing out test results to prevent future errors. Update: 03/20/13:Patient B will receive a HIPAA letter of notification.

Outcome:

The WHC staff who are tasked with sending the letters were re-educated by the AO on the requirement to confirm patient identifiers before placing the letter in the envelope for mailing.