VA Health Care Upstate New York (VISN 2)

Report ID: SPE000000061588, U.S. Department of Veterans Affairs

Reported Entity: VISN 02 Syracuse, NY

Issue:

A medical student's shift handoff tool was left unsecure in a public area and found by a nurse manager. The shift handoff tool that included personally identifiable information (PII) and protected health information (PHI) of 10 different Veterans currently admitted to the Medicine department was left out on the counter in the coffee shop. The report was printed early in the morning and was found in the coffee shop mid afternoon the same day. After discussion with the canteen clerk, the list was not there in the morning as she had cleaned the area and nothing was there. As a result, it is likely that the list was only there for a few hours until found by the nurse manager and placed in a secure area until turned in to the Privacy Officer. The Chief of Medicine and Administrative Officer have been working to purchase cabinets for wall-mounted computers and roll around carts, for which IT would provide the PCs, in the Medicine inpatient units. This will allow for increased electronic access to patient information needed for shift handoff by the residents and medical students, and less use of the paper report. In addition, the plan is to reduce the identifiers on the report by removing the full patient name and last 4 SSN of the report and replacing it with the patient's last name and date of birth. Update: 04/27/11:The ten patients will receive a letter of notification.

Outcome:

Chief of Medicine educated medical students and residents on the requirement to safeguard the shift handoff tools when carrying them on rounds and to ensure they are placed in the gray, locked shredding bins when no longer need. VISN 2 Clinical Informatics group looking at removing the last 4 SSN from the shift handoff tool and replacing with patient's DOB to reduce risk of patient information being inappropriately exposed.