VA Health Care Upstate New York (VISN 2)

Report ID: SPE000000077123, U.S. Department of Veterans Affairs

Reported Entity: VISN 02 Syracuse, NY

Issue:

The Emergency Department Service Chief reported to the Privacy Officer (PO) that Patient A received the discharge instructions with Patient B's patient identification label on it, resulting in Patient B's name, full SSN, and DOB being inappropriately disclosed to Patient A. The Service Chief confirmed that both patients received the correct discharge instructions and identified that the error occurred when Patient A's identification label was placed on Patient B's completed discharge instructions in error and given to Patient B. The Service Chief contacted Patient B and asked that he return the discharge instructions sheet to the VA so it could be properly destroyed. Patient B stated he would be in the hospital next week for an appointment and would bring back then. The Service Chief will ensure Patient B's discharge instructions sheet is corrected with the correct patient identification label before sending to HIMS for scanning. The Service Chief will also re-educate the provider and nursing staff on the requirement to confirm the correct patient identifiers when completing the discharge instructions to avoid future errors. Update: 06/26/12:Patient A and B will be sent a letter offering credit protection services.07/24/12:On further review only Patient B's information was disclosed to Patient A. Only Patient B will be sent a letter offering credit protection services.

Outcome:

ED Service Chief confirmed that Patient B destroyed (shredded) his discharge instructions that contained Patient A's identification label. The ED physician was counsled on his error and educated to confirm patient identifiers before handing the discharge instructions to the patient.