VA Health Care Upstate New York (VISN 2)

Report ID: PSETS0000084635, U.S. Department of Veterans Affairs

Reported Entity: VISN 02 Syracuse, NY

Issue:

Nurse Manager for the Emergency Department (ED) reported to the Privacy Officer that two patients who were in the ED at the same time received each other's medication lists when given to them in error by the ED physician. The error was realized by the ED physician after Patient A had been discharged and went home. Patient B was still in the ED and the medication list for Patient B was retrieved from him before he reviewed it, avoiding any inappropriate disclosure of PHI/PII of Patient A's information. Patient B was given a correct copy of his medication list. The ED Physician contacted Patient A at home who confirmed receipt of Patient B's medication list and stated he would shred it. The Nurse Manager confirmed that Patient A was sent the correct medication list and that the ED physician was aware to confirm patient identifiers before providing the medication list to the patient to avoid future errors. Update: 01/15/13:Patient B will be sent a letter offering credit protection services, since his name and date of birth were disclosed to Patient A and the list was taken off VA property. The risk of Patient A's information is minimal since it was retrieved immediately.

Outcome:

ED Nurse Manager confirmed that the provider was educated on confirming patient identity before releasing discharge instructions to patients.