Clement J. Zablocki Veterans Affairs Medical Center

Report ID: PSETS0000104184, U.S. Department of Veterans Affairs

Reported Entity: MILWAUKEE WI - 695

Issue:

A series of medications were mislabeled by a VHA employee and sent to incorrect patients. In comparison to the other three tickets from this facility, recently, of the same nature, this is a consolidated ticket for 13 patients whose medications and medication information was inappropriately disclosed to other patients. Please see PSETS0000104132 as example. Mitigation as of 05/14/14 regarding the use of the label-printing machine: Instead of a two-step process of hitting Retrieve and then Print Label we changed the preferences within the system so that the label prints only when the Retrieve button is pressed. This will eliminate the possibility of a label printing without the Retrieve button being pressed. The label is then visually double checked by the mail person and then affixed to the package without covering the original Pharmacy label. An additional visual double check will be performed daily at 3:00 PM for the foreseeable future. In addition, the employee has agreed to have his staff offset the Pharmacy label so that the large shipping sticker is easier to affix without covering the Pharmacy label. Also, Pharmacy is reducing/eliminating the use of certified mail, and packages without barcodes so that every Pharmacy package is processed in one way, through one process, and using the Retrieve function every time instead of processing those items through the old system.

Outcome:

05/15/14: HIPAA notifications will be sent to 13 patients.