Beckley VA Medical Center

Report ID: PSETS0000095209, U.S. Department of Veterans Affairs

Reported Entity: BECKLEY WV - 517

Issue:

Veteran A received a prescription intended for Veteran B and Veteran B received a prescription intended for Veteran A. On September 20, 2013, a prescription for the same medication and same directions for two different Veterans with the same last name were mixed up before they were mailed. Veteran A received the prescription intended for Veteran B and Veteran B received the prescription intended for Veteran A. On September 27, 2013, Veteran A called to state he had received his prescription in the mail and that the medication and directions were correct, but the name on the label was not his correct full name. The last name was correct, but the first and middle name were incorrect. After review it was determined that the same exact prescription was filled for two different Veterans with the same last name on September 20, 2013. Veteran B was contacted and he stated that he did receive his prescription, but had not noticed that the name listed on the label was wrong. Veteran B was not at home when he was first contacted, but when he returned home, he called the Chief, Pharmacy to report that the name on his bottle was incorrect, as expected. Both Veterans were told that a new prescription would be mailed to each of them with the correct name listed on the label. The Chief, Pharmacy apologized to the two Veterans for the mistake that was made. The pharmacy staff member involved in packaging the mailed packages incorrectly was reminded that it is expected that all names are double checked before packages are mailed to Veterans.

Outcome:

09/27/13: Both Veterans will be sent HIPAA notification letters due to Protected Health Information (PHI) being disclosed.