VA Southwest Health Care Network (VISN 18)

Report ID: SPE000000065779, U.S. Department of Veterans Affairs

Reported Entity: VISN 18 El Paso, TX

Issue:

A copy of Veteran A's medical record was returned to the facility by Veteran B. The medical record information in packet consisted of a copy of the medical record with full patient name, full SSN, encounter information, laboratory, pharmacy, and medical information. The initial fact-finding determined that a sealed UPS envelope and copy of the medical record was generated and labeled correctly for mail-out to Veteran A. However, upon creation of UPS label by mailroom personnel - Veteran B's mailing information label was incorrectly placed on the UPS envelope then delivered by UPS to Veteran B. Veteran B returned the entire packet to the Medical Record Section and expressed concern/complaint about the mislabeling and noted that correct mailing label was visible next to incorrect UPS label. The package had been opened by Veteran B, who immediately returned the packet/envelope with the entire copy of the medical record upon seeing that information was not his and was intended for Veteran A. An internal fact-finding to be directed to the Supervisor/Chief of the Mail Room to back-track and address the issue of UPS mislabeling, mishandling and misrouting. Note that the originating Section (Medical Records-Release of Information) has validated correct routing, labeling, correct accounting of disclosures in the DSS-ROI software, and via phone verification has verified the correct delivery of other packets mailed on that same date via UPS, to rule out chance of any other mishandling/mislabeling errors that may have been in group of packets/workload prepared for UPS mail-out on same day. Update: 08/15/11: Veteran A will be offered credit protection services, as his full SSN was disclosed.

Outcome:

09/28/2011: Note that original packet of information which had been incorrectly labeled and received by incorrect Veteran was returned in total by the Veteran who had received the incorrect package - to originating Section - Medical Records/Release of Information staff. In order to prevent this type of incident from occurring again, the following corrective action will be taken: 1. For all ROI(Release of Information Section) mail-outs, both employees in the mailroom will check and confirm that the mailing information on the packet label and the mailing label (UPS or otherwise) are exact, and 2. An email confirmation will be sent to the supervisor. This action will ensure there are two sets of eyes examining the mailing information on the labels prior to the ROI mail-out leaving the building. Letter offering credit monitoring and notification to affected Veteran prepared/provided to Director for signature and redacted copy of letter uploaded to SPE/NSOC ticket.