VA New England Healthcare System (VISN 1)

Report ID: SPE000000061766, U.S. Department of Veterans Affairs

Reported Entity: VISN 01 Manchester, NH

Issue:

Patient A had an appointment in Radiology. The check-in clerk checked in Patient A and then went to print out his wrist band. Unfortunately the clerk didn't select the new patient button and printed out the previous patient's wrist band (Patient B). The clerk put the wrist band on Patient A. The technician called Patient A and verbally confirmed who the patient was. Patient A was then taken to the MRI station and once again verbally confirmed that the patient was the correct patient. The wrist band was never verified, just a verbal verification. Then procedure was done and Patient A went home with the wrist band on. Patient A cut off the wrist band and left it in his car. Then three (3) days later he saw the wrist band. He went to destroy it but noticed that the wrist band was of another patient. Patient A immediately called the VA and spoke to the call center and made a report of what happened and the call center called the Radiology manager and reported the incident. The manager then called the Patient A to verified what happened and told the patient to destroy the wrist band. Then the Radiology manager called the Privacy Officer and reported the incident. The Privacy Officer spoke to all parties involved and patient destroyed the wrist band. Update: 04/29/11;The wrist band contained Patient B's name and date of birth. Patient B will receive a letter offering credit protection services.

Outcome:

Instructions were given to verify patient name with looking at the wrist band.

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: SPE000000061781