VA Eastern Kansas Health Care System - Dwight D. Eisenhower VA Medical Center

Report ID: PSETS0000096253, U.S. Department of Veterans Affairs

Reported Entity: EASTERN KANSAS HCS(Topeka-Leavenworth) - 589A6

Issue:

An error was made in the dispensing of an outpatient prescription for a controlled substance for the exact medication & dosage to the wrong Veteran. Details follow: 10/09/2013: Pharmacy technician recorded removal of oxycodone 5 mg tablets, #120, in the CII-Safe and VistA systems for Veteran1. The technician processed the RX through the Script Pro packaging system. The technician had to leave the area momentarily to retrieve a prescription vial in order to package the medication. When Pharmacy Tech. (RxTech) returned to the filling area, RxTech scanned the drug into the Script Pro packaging system which resulted in the generation of a label for the oxycodone 5 mg tablets for Veteran2. Veteran2s RX was also issued for #120 tablets. The technician did not realize the error in scanning the drug twice and placed the vial, labeled for Veteran2, with the paperwork for Veteran1. The checking pharmacist did not detect the error. The pharmacist who packaged the medication for shipping via UPS did not detect the error. The error was not detected during the monthly controlled substance inspection on 10/10/2013 or during any subsequent pharmacy inventories since the RX for Veteran2 was never taken out of the CII-Safe or VistA. (It was basically a documentation/labeling/dispensing error.) On 10/16/13, Pharmacist recorded removal of oxycodone 5 mg tablets, #120, in the CII-Safe and VistA systems for Veteran2; but was not able to process the RX through the Script Pro packaging system since it had been processed through the system on 10/09/2013. The pharmacy technician contacted Veteran1 by telephone, who confirmed that he had a vial of oxycodone 5 mg tablets that were labeled for Veteran2. Since the quantity was the same as what Veteran1 had expected, he had not noticed that another patients (Veteran2) name was on the vial. Since Veteran2s RX was issued with directions to take 1 tablet every six hours and Veteran1 takes 1 tablet every six hours as needed, there were no issues with over- or under-dosing on Veteran1s part. Veteran1 was advised that a correctly-labeled vial would be sent to him via UPS. Veteran1 agreed to transfer the remaining oxycodone 5 mg tablets from Veteran2s vial to his correctly-labeled vial and also agreed to return the vial labeled for Veteran2 to the VA pharmacy. A postage-paid mailer addressed to the VA Pharmacy was included in the UPS package sent to Veteran1. The Information of Veteran2 that was sent to Veteran 1in error included the following information that was printed on the RX label: RX number (would be unable to do anything without other identifying information of individual's & this was returned as promptly as possible) Patient name Drug name, strength, quantity, and directions for use (which were exactly the same as Veteran1) Prescriber name (Non-Applicable)

Outcome:

11/01/13: Veteran 1 will receive a HIPAA letter of notification.