VA Health Care Upstate New York (VISN 2)

Report ID: PSETS0000087410, U.S. Department of Veterans Affairs

Reported Entity: VISN 02 Syracuse, NY

Issue:

Patient A presented to Primary Care Clinic and reported that he had received several copies of Patient B's medical records when receiving his own in the mail. The copy of Patient B's medical records were turned into the Administrative Officer for Primary Care and secured in her office until reported and turned into the Privacy Officer. After further review it was determined that Patient A's request for a copy of his medical records was processed the same day as Patient B's request by the Release of Information Department. This resulted in Patient A's name, date of birth, address, diagnoses, medications, procedures and lab results being inappropriately disclosed to Patient B. The Health Information Management Service (HIMS) Chief was notified and reviewed the error. It was determined that both requests for records were sent to the printer at the same time and combined before released by an employee who was tasked to assist with the Release of Information backlog , resulting in the error. The HIMS Chief has educated the employee on confirming patient identifiers on the documents before releasing when sending multiple requests to the printer at the same time to avoid future errors. Update: 04/01/13:One patient will be sent a HIPAA notification letter.05/22/13:This was determined to be HITECH reportable by VHA Privacy Office.

Outcome:

The records were retrieved from the patient that received them in error and properly destroyed. In addition, the records requested by Patient B were re-printed by the Release of Information Department and sent to the patient. Lastly, the HIMS employee who had been assigned to assist with the ROI backlog was re-educated regarding the requirement to confirm patient identifiers before mailing out the printed records to prevent future occurrences.