VA Mid-Atlantic Health Care Network (VISN 6)

Report ID: SPE000000061589, U.S. Department of Veterans Affairs

Reported Entity: VISN 06 Beckley, WV

Issue:

A Beckley VAMC staff physician was asked to write a letter describing a Veteran's present medical condition. This Veteran is presently an inpatient at Beckley VAMC. This letter was requested by two of the adult sons of the Veteran. However, the medical decision maker at this time is a court appointed agent of the State of West Virginia who is an employee of the WV Department of Health and Human Services. The physician was not sure if he should give this letter to the sons. Nevertheless, he printed the letter off and laid it on his desk, but did not sign it. The physician shares his office with a medical resident. This morning, while the physician was out of the office, but the medical resident was there, one of the adult sons presented and requested the letter. The medical resident gave the letter to the son. Since the medical decision maker is a court appointed agent of the West Virginia Department of Health and Human Services, the son who was provided the letter was not authorized to receive it. The letter explains what the Veteran's medical problems are, and what sort of care the Veteran needs to receive in the home once he is discharged. Update: 04/27/11:The court appointed agent of the West Virginia Department of Health and Human Services will receive a letter of notification.

Outcome:

This event was discussed at length with both the physician and the new resident. It was the new medical resident who provided the document. Appropriate education was provided, including privacy training. The physician and the medical resident discussed this event with the Chief of Staff, the Associate Director, the Nurse Executive, Acute Care Service Line Chief and me (Privacy Officer) . This has resulted in the heightened awareness of privacy protocol by both the physician and the resident. The document was returned in less than 24 hours to the physician.