VA Southwest Health Care Network (VISN 18)

Report ID: PSETS0000085788, U.S. Department of Veterans Affairs

Reported Entity: VISN 18 Phoenix, AZ

Issue:

Outpatient pharmacy supervisor reports Veteran A returned medications to a distant CBOC today. Veteran A reported that upon discharge last night, nurses gave him his own discharge medications as well as the discharge medications of Veteran B. When Veteran A realized after discharge that he had someone else's medications, and returned them to a CBOC near his home today. Because of his home location, they were returned to a CBOC belonging to a different VA Medical Center and are being shipped back to PVAHCS Pharmacy, but are recovered to VA custody. Further remediation to follow. Update: 02/14/13:Veteran B will be sent a HIPAA notification letter.

Outcome:

Root causes were determined to be similarity of patient names and SSN; changing discharge plan of Veteran B caused his discharge medications to be placed on the ward, although by the time of discharge Veteran A was to be the only patient discharged; unusual procedure where Nursing rather than Discharge Pharmacist dispensed discharge medications, due to the late-night hour of discharge of Veteran A; and Nursing staff error in not checking the medication bags.Corrective actions taken were recovery of mis-dispensed medication and paperwork on 2/13/2013; discussion of incident between ward staff and Nursing management to provide education on need for thorough medication label review prior to dispensing; and notification letter sent to Veteran on 2/28/2013 (redacted copy in Attachments). No further actions are planned and PO requests closure.