VA Healthcare - VISN 4 (VISN 4)

Report ID: SPE000000065561, U.S. Department of Veterans Affairs

Reported Entity: VISN 04 Pittsburgh, PA

Issue:

Patient A realized that the patient wristband placed on his wrist was not his. The wristband on his wrist pertained to Patient B. The wristband contained Patient B's name and full SSN.Patient A identified the mistake within 30 minutes and reported it to the clinic manager. The clinic manager removed the wristband and then walked the patient up to the front desk and corrected the error. The clerk indicated that she must have made a mistake and placed the incorrect wristband on the patient. It was also verified that this was the only patient affected and no other patient wristbands were incorrectly placed on any other patients. Update: 08/09/11:Patient B will be sent a letter offering credit protection services, due to full name and full SSN being exposed.NOTE: There were a total of 81 Mis-Handling incidents this reporting period. Because of repetition, the other 80 are not included in this report, but are included in the "Mis-Handling Incidents" count at the end of this report. In all incidents, Veterans will receive a notification letter and/or credit monitoring will be offered if appropriate.

Outcome:

The employee was reeducated by the clinic supervisor regarding this type of error and to ensure proper identification of patients when putting on patient wristbands. The clinic manager will conduct a post incident training brief at the next staff meeting and will remind all staff to perform proper ID authentication and ensure patient wristbands are checked at every step during the treatment process.