VA Southwest Health Care Network (VISN 18)

Report ID: SPE000000062421, U.S. Department of Veterans Affairs

Reported Entity: VISN 18 Phoenix, AZ

Issue:

Today, 5/12/2011, a Veteran reported to the Privacy Officer (PO) that another patients identity is in two of his progress notes. He noticed this when he received his medical records several weeks ago, has an appointment today. The PO's initial review of progress notes confirms another patient with the same last name and different SSN. The Veteran did not bring in his copies for retrieval but promises to shred documents upon return home today. The Veteran's appointment request was sent to Release of Information (ROI) Supervisor for records review for additional chart review. Administrative reporting, physician contact, and investigation to ensue. Update: 05/12/11:The Privacy Officer went through Release Of Information to look through the Veterans record to confirm the information that the Veteran reported. All medical data in the record was correct and pertained to the appropriate Veteran, however another Veteran's name and SSN was contained within the body of a progress note. The other Veteran will receive a letter offering credit protection services.

Outcome:

Physician Supervisor spoke with physician about incident. She also met with other physicians in the service line to remind them to be extra attentive when copying and pasting patient information from endow reports and also into pathology letters. Review of patient chart confirms other correct material. Double check of deceased patient's chart also. NOK notification letter mailed to NOK.