Search Privacy Violations, Breaches and Complaints
This database was last updated in December 2015 ago and should only be used as a historical snapshot. More recent data on breaches affecting 500 or more people is available at the U.S. Department of Health and Human Services’ Breach Portal.
Northwest Network (VISN 20)
Mentioned in a privacy incident report created by the U.S. Department of Veterans Affairs on March 22, 2013. Also cited in 208 other reports.
Report ID: PSETS0000087108, U.S. Department of Veterans Affairs
Reported Entity: VISN 20 Boise, ID
Issue:
Pharmacy received a call today from [Reporting Veteran], stating that [they] had received medications for 3 other veterans along with [their] refrigerated medications. I did some preliminary investigating to try to determine where the error occurred. The only conclusion was a packaging error. I called [Reporting Veteran] and asked her to mail the medications and paperwork that did not belong to her to the pharmacy. While talking with her I asked her whether all 8 coolers were addressed to her. Her response was that 5 of the coolers had her name and address on both address stickers and 3 of the coolers had her address as well as another persons address on it. Upon further inquiry, I determined that the yellow pharmacy address stickers were correctly addressed (5 coolers to [Reporting Veteran], and 1 cooler apiece for the 3 other Veterans involved) but the mailrooms UPS stickers were all addressed to [Reporting Veteran]. She graciously agreed to return all medications and paperwork to us.The 3 other veterans involved are as follows:[V1][V2][V3]All medications were custom compounded from Custom medical and have been reordered. Update: 03/22/13:Three Veterans will be sent a HIPAA notification letter.05/28/13:This was determined to be non-HITECH reportable by VHA Privacy Office.
Outcome:
The Facility Privacy Officer (PO), Mikel Beckham, conducted a thorough investigation into the cause of the miss mailing and determined it to be human error, not double checking the yellow address label affixed by pharmacy prior to attaching the UPS mailing label. The PO explored several process change options to see if any other preventative measure could be put into place. Of all the process changes and/or extra security steps for mail out medications the PO determined the current process, with an error rate of less than 0.06%, is still the best procedure. The Service Chief and Department Supervisor over the mail staff were notified and a focused privacy reminder education was conducted. The education was aimed at reminding the staff to always double check the yellow address labels already affixed to the sealed medications packages before attaching the UPS mailing label.