Northwest Network (VISN 20)

Report ID: PSETS0000084465, U.S. Department of Veterans Affairs

Reported Entity: VISN 20 Portland, OR

Issue:

A man without a photo ID was treated in the VA Emergency Department and his treatment was documented in the medical record of a Veteran with the same name on two occasions in December 2012. The man was not given medical records but he did have a patient wristband which had his name, full SSN, and date of birth printed on it. The Veteran's medications and general medical history would have been discussed with the man as part of the intake process for treatment. It has not been verified if the man claimed to have been the Veteran with the same name, or if the incident was caused by employee error. The information collected is being relocated to the correct record. Update: 01/11/13: On 12/23 a man arrived at the ED triage desk and gave his first and last name but he did not know his SSN. One of the nurses was certain she had checked him in earlier in the month, and upon checking EDIS (VA ED Patient Tracking software) learned that a Veteran with that name had checked into the ED on 12/13 but he had a different DOB. The patient was very uncooperative with questions and close to an hour was spent trying to get information from him to find out why he was here and to make sure the right person was checked in. Nurses checked for any identification on him and found nothing, so he was checked in using a CPRS record with a pseudo SSN instead of selecting an existing record. Once the secondary triage was done, two other nurses also felt fairly certain that they had seen the patient earlier in the month. When compared, the EKG taken that day was similar to the EKG taken on the Veteran they initially believed him to be who had checked in to the ER on 12/13. However, the pre-op EKG taken on 12/4 for that Veteran was not the same. The RN's were so certain that the patient was seen previously, the home number in the Veteran's chart was called. The Veteran was home so they knew they were correct in using a pseudo SSN for the patient who had just presented in the ED. After further review, it was found the man is not eligible for VA care. He has the same first and last name as another Veteran with the same name and physical description. the ED nurse looking into the issue identified two ED visits (12/12 and 12/13/2012) in the record for the Veteran they had almost selected. The ED Chief is working with his employees on removing the incorrect information from the Veteran's record and having it entered into the man's CPRS chart as treatment for a Humanitarian Emergency. The ED staff say the man was not given any documents containing the Veteran's PII/PHI at either of the visits because he walked out before they had finished treating him. He was given a wristband to wear that contained the name, full SSN, and DOB. The name was the same as his own, of course. He left with the wristband still on his arm. Other medical information generally discussed during triage (medications, history, etc) would have been discussed from the record, but the providers note that he was not cooperative. The ED providers evaluating the situation called a meeting to discuss the issue. 01/28/13: The DBCT reviewed this ticket and determined that notification is required. The Veteran will receive a letter offering credit protection services.

Outcome:

NA

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: PSETS0000084467