VA Southeast Network (VISN 7)

Report ID: SPE000000080148, U.S. Department of Veterans Affairs

Reported Entity: VISN 07 Columbia, SC

Issue:

Veteran A and his wife presented to the Dorn VA Medical Center Patient Representatives office on 09/12/12 to inform her that Veteran A had inadvertently received medical records by mail, which were intended for Veteran B. Upon research, the Chief of Health Information Management Service (HIMS), discovered that the medical records were released by a Release of Information (ROI) clerk. The Chief of HIMS also discovered that Veteran B's medical records were scanned into Veteran A's record by a Fee Basis staff. Veteran A and Veteran B have the same first and last name. The File Room Supervisor has been asked to remove the documents. The information disclosed included Veteran B's full name, date of birth, full SSN on one document, and non-VA health information (ER record). Veteran A also received a letter mailed by Release of Information Office on 08/22/12 which pertained to an orthopedic surgeon not being able to complete a medical form he had submitted. In the body of the letter, Veteran Cs last name was mentioned. Veteran A has never been seen by the orthopedic surgeon, and, therefore, had not submitted a form to complete. No other identifying information pertaining to Veteran C was included. This document was also provided to the Patient Representative. The error apparently occurred on 07/13/2012 and 08/22/12. Update: 09/14/12:Veteran B will receive a letter offering credit protection services. Veteran C's name alone was not enough personally identifiable information or protected health information to warrant notification or credit protection services.

Outcome:

Staff has been re-educated on the need to safeguard patient information.