VA Southwest Health Care Network (VISN 18)

Report ID: PSETS0000081840, U.S. Department of Veterans Affairs

Reported Entity: VISN 18 Phoenix, AZ

Issue:

Today, 10-31-2012, Veteran A notified PO that he had received copies of Veteran Bs medical records in the mail. He had previously requested that medical records be sent to another medical center. Instead, he received his records and those of another Veteran by the same name, coincidentally with a very similar DOB. The Veterans records consisted of: 18 pages of progress notes and lab results of medical information and personally identifiable information (SSN and address).ACTIONS:1)ROI Supervisor was contacted. Records will be mailed to the medical center today, after calling the Veteran to apologize, obtain accurate information and reassure.2)Root cause investigation underway.3)Retrieval of documents planned during Veterans next appointment here on 12/8/2012; 2 hour drive and short TAT of documents by mail.4)Provided contacts and phone numbers for additional clinical concerns.Additional notification and investigation to ensue. Update: 12/11/12:Veteran B will be sent a letter offering credit protection services.

Outcome:

Investigation by the ROI Supervisor into the root cause determined that mis-scanning of another same named Veteran's materials into this Veteran's chart is the origin of event. This occurred in 2004. Identified staff is no longer a scanner. Supervisor provided current staff with quality scanning guidelines as a precaution. Supervisor and PO have spoken with reporting Veteran on several occasions who is aware of resolution to his chart and the notification process to other Veteran. Investigation concluded.

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: PSETS0000081818