VICTOR VALLEY GLOBAL MEDICAL CENTER

Report ID: BI7G11, California Department of Public Health

Reported Entity: VICTOR VALLEY GLOBAL MEDICAL CENTER

Issue:

Based on interview and record review, the facility failed to maintain the privacy and confidentiality of one patient's medical record (Patient A) in which a medical records clerk (Employee 1) released Patient A's protected health information (PHI) to the wrong patient (Patient B). This failure had the potential to result in unauthorized persons to use the disclosed information in a way not authorized by the patient.Findings:On January 24, 2011, an investigation was conducted on an entity reported event involving the breach of one patient's (Patient A) medical records by a medical records clerk (Employee 1) of the facility.Review of the letter received by the California Department of Public Health (CDPH) by fax, dated December 14, 2010, revealed that the facility's privacy officer (PO) was notified that a patient (Patient B) had inadvertently received another patient's (Patient A) medical records and called the facility to report that the records did not belong to him.The record given in error to Patient B included Patient A's: face sheet (contains demographics), discharge summary, history and physical, physician and nurses' progress notes, laboratory and radiology reports, and physician consult reports.During an interview with Employee 1 on January 24, 2011 at 4:25 PM, when asked how the records were sent in error, Employee 1 stated, " Patient A came in to request records. The records were in storage. Patient A was born in 1962 and Patient B in 1952. I accidentally gave Patient A's records to Patient B. Once Patient B got home he called because he had received the wrong records (Patient A's) and said he was never an inmate."A review of the facility's policy and procedure titled, "Record Preparation for the Release of Protected Health Information (PHI)," dated July 2009 was conducted. The policy indicated,"...d. Prior to photocopy/printing review each page of the medical record to ensure that only the patient information in the the medical record is only for the specific patient request...e. If any documents found in the patient's medical record belongs to another patient, immediately remove that piece of information from the record and file it with the appropriate patient's medical record."The failure of Employee 1 to follow the facility's policy and procedure and verify each document being given to Patient B belonged to Patient B, resulted in Patient A's PHI being released to Patient B without authorization.

Outcome:

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