LOMA LINDA UNIVERSITY MEDICAL CENTER

Report ID: EDNQ11, California Department of Public Health

Reported Entity: LOMA LINDA UNIVERSITY MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to ensure the confidential treatment of protected health information (PHI), when Patient A received discharge paperwork addressed to Patient B. This resulted in a breach of PHI.FindingsOn 3/5/12 at 10:30 AM, a member of corporate compliance (Staff 1) was interviewed regarding an entity reported event of providing the PHI for Patient B to Patient A, upon his discharge from the emergency room (ER) on 2/13/11.Patient A was admitted to the ER on 2/13/11 at 2:50 PM, with the chief complaint of a skin irritation. He was discharged home at approximately 11:50 PM, and had been provided with 5 pages of information labeled for Patient B. Patient A returned the documents, which he noted did not have his name on them, when he came back for a clinic visit 10 ten days later.Patient B was admitted to the same ER on 2/13/12 at 2:00 AM, and later admitted to the hospital at 8:03 PM, for an altered level of consciousness. Staff 1 could not explain how patients admitted to the ER approximately 12 hours apart, and discharged (one to home and one to the hospital) 3 hours apart, could have their paperwork inadvertently switched.On 3/8/12 at 11:40 AM, Staff 2 from corporate compliance, stated she had investigated the entity reported event, and "discovered the error occurred when the resident and intern who had cared for both Patients A and B were dictating the Discharge Summary notes for Patient A. During the course of their dictation they had inadvertently used Patient B's name, but had described the course of treatment for Patient A". She confirmed this error was a breach.

Outcome:

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