SHARP CHULA VISTA MEDICAL CENTER

Report ID: PBI911.01, California Department of Public Health

Reported Entity: SHARP CHULA VISTA MEDICAL CENTER

Issue:

Based on interview and document review, the hospital failed to ensure that personal and protected health information (PHI) was safeguarded for 1 of 2 sampled patients (1). Patient 2 was discharged from the hospital with Patient 1's written medication prescription in addition to her own prescription. Patient 2's spouse discovered the error and brought it to the hospital's attention. As a result of this failure, Patient 2 had access to Patient 1's PHI listed on the written prescription. Findings:A review of Patient 1 and 2's medical record was conducted with the Women's Services Nurse Manager (WSNM) on 10/8/13 at 3:44 P.M. Patient 1 was discharged from the hospital on 9/30/13 per the hospital's Facesheet. Patient 1's Depart Summary (patient's copy of discharge medications and instructions) dated 9/30/13, indicated that the physician prescribed ibuprofen 600 milligrams (mg) by mouth every 6 hours. The Depart Summary was not signed by Patient 1 or the discharging Registered Nurse (RN) 1. Patient 2 was discharged from the hospital on 9/30/13, per the hospital's Facesheet. Patient 2's Depart Summary dated 9/30/13, indicated that the physician prescribed Hydrocodone-acetaminophen 5 mg-325 mg (pain medication) by mouth every 4 hours as needed for mild pain. The Depart Summary was not signed by Patient 2 or RN 1. An interview was conducted with RN 1 and the WSNM on 10/8/13 at 6:00 P.M. RN 1 stated that Patient 2's husband called to inform the Charge Nurse, that Patient 2 had received a written prescription which belonged to Patient 1. RN 1 stated that she remembered seeing two written prescriptions attached to Patient 2's Depart Summary. In addition, RN 1 stated that she did not look at both prescriptions because she saw Patient 2's name on the top prescription and thought the same name appeared on the second prescription. RN 1 acknowledged that she did not verify if both prescriptions belonged to Patient 2, and that she did not verify them with the Depart Summary. On 10/8/13 at 6:15 P.M., RN 1 stated that, the Depart Summary is read to the patient and then, both the patient and discharging RN sign the Depart Summary. In addition, RN 1 stated she was not aware that Patient 2 received Patient 1's prescription until after Patient 2's husband had brought it to the hospital's attention.RN 1 stated that she did not verify Patient 1's name on the prescription when she gave it to Patient 2. RN 1 acknowledged that it was the responsibility of the discharging RN to review and sign the Depart Summary with the patient, to ensure that follow up instructions and medications prescribed for the patient were accurate. The hospital's policy titled "Discharge Summary" revised 07/2011 indicated that patient identification was to be included on all discharge instructions including medications; dated timed and authenticated by the person responsible for providing the service. The hospital's policy titled "Health Information: minimum Necessary Access, Use & Disclosure" revised 07/2011 indicated reasonable measures must be taken to limit the disclosure of protected health information. These policies were not followed when Patient 2 received Patient 1's prescription. The lack of patient identification and staff authentication, did not ensure that Patient 1's PHI was safeguarded.

Outcome:

Deficiency cited by the California Department of Public Health: Patients' Rights

Related Reports:

2 other violations reported on the same date. Note that other citations may be about the same event: 65Q911.01, VSX011.01