VA Health Care Upstate New York (VISN 2)

Report ID: SPE000000072389, U.S. Department of Veterans Affairs

Reported Entity: VISN 02 Syracuse, NY

Issue:

Patient A's wife reported that Patient B's medical information was in her husband's medical records. The wife reported that this was identified when Patient A's doctor was asking him about his past medical issues and they weren't issues he had. This led the patient to be concerned that other information in his record was inaccurate. The HIMS Manager reviewed further and determined that the documentation in Patient A's medical record was different than the documentation the patient received from Release of Information (ROI) when requested. Specifically, the records selected for release and released through the ROI software contained records on Patient B, although they had Patient A's name on them. None of the notes selected for release in the ROI software were actually in Patient A's record. It was determined that this was due to a past software glitches in the ROI software whereby the records to be released were not updating correctly from previous patient, when selecting new patient. This resulted in Patient B's records being released to Patient A in error. The software glitches has since been fixed correcting this issue. Patient B's name, address and protected health information were compromised. Update: 03/02/12:Patient B will receive a letter of notification.

Outcome:

The HIMS Manager thoroughly reviewed Patient B's medical record and confirmed that no information regarding Patient A was included. The error was due to an ROI Record Manager software glitch which was previously resolved by VA in 2003.

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: SPE000000072394