VA Mid South Healthcare Network (VISN 9)

Report ID: SPE000000064897, U.S. Department of Veterans Affairs

Reported Entity: VISN 09 Nashville, TN

Issue:

Patient A contacted the pharmacy call center in Murfreesboro, TN and reported he received a medication belonging to Patient B at his temporary address in Southport, NC. Upon investigation, a pharmacy administrator learned Patient A had given his temporary address to a clerk in the OIF/OEF clinic (Nashville campus) who inadvertently entered the information into Patient B's CPRS record. Patient A did not take any of the medication and disposed of it. Pharmacy corrected Patient B's address in the computer and re-sent the medication. Update: 07/21/11: Patient A will receive a letter of notification.

Outcome:

7/28/11 - During a clinic visit, Patient A requested the clerk change his address in the computer. The clerk was working in Patient A 's and Patient B's record, simultaneously, and inadvertently entered the address change into Patient A's record. Pharmacy processed a refill request for Patient B and mailed it to Patient A's address listed in the computer. To remediate this issue, a new process has been implemented in which the Veteran will be required to submit a written request for demographic changes versus the clerk accepting a verbal request. The clerk in question will undergo additional privacy training. Pharmacy corrected Patient B's address in the computer and re-sent his medication. Lastly, Veteran A disposed of the mis-mailed medication. HIPAA Notification letter mailed. PO requests closure.

Related Reports:

2 other violations reported on the same date. Note that other citations may be about the same event: SPE000000064918, SPE000000064928