SAN ANTONIO REGIONAL HOSPITAL

Report ID: 8TWR11, California Department of Public Health

Reported Entity: SAN ANTONIO REGIONAL HOSPITAL

Issue:

Based on interview and record review, the facility failed to ensure the confidential treatment of protected health information for Patient A, when Patient A's laboratory requisition order was inadvertently faxed with Patient B's paperwork to Animal Control.Findings:During a phone interview on April 14, 2015 at 4:15 PM, with the Director of Health Information Management (DOHIM) she stated, the breach occurred on April 6, 2015, when the Medical Assistant (MA) printed the paperwork for Patient B because she was bitten by a cat Patient A's laboratory(a list of tests to be done) requisition order was on the printer and the MA picked up both papers together and faxed them to the animal control facility.During a phone interview on April 17, 2015 at 2:13 PM, with the MA he stated,he was printing the providers notes regarding the animal bite report. He picked up the provider notes off from the printer and didn't realize there was another page under the provider notes. The MA stated,"I did not think to check the documents before faxing them to animal control."A review of Patient A's lab requisition send to the animal control facility included: Patient A's date of birth, age, sex, weight, height, allergies, home address, work phone number, health insurance, medical record number,Diagnosis, and the test order request.

Outcome:

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