Search Privacy Violations, Breaches and Complaints
This database was last updated in December 2015 ago and should only be used as a historical snapshot. More recent data on breaches affecting 500 or more people is available at the U.S. Department of Health and Human Services’ Breach Portal.
SANTA CLARA VALLEY MEDICAL CENTER
Cited by the California Department of Public Health for violations of California’s Health and Safety Code relating to medical privacy during an inspection that began on July 25, 2014. Also cited in 90 other reports.
Report ID: 7Z8R11.02, California Department of Public Health
Reported Entity: SANTA CLARA VALLEY MEDICAL CENTER
Issue:
Based on interview and record review, the hospital failed to follow their policy and procedure regarding "Mail-order Shipping Execution/Delivery Confirmation Tracking" for one of two sampled patients (1), when the hospital mailed Patient 1's medication to another patient. The failure resulted in Patient 2 receiving and taking the wrong medication. Findings:The California Department of Public Health received a faxed report on 5/22/13, which indicated Patient 2 received two packages from the pharmacy, via mail. Both packages contained Patient 2's name on the shipping label but one of the packages contained a medication bottle which belonged to another patient (Patient 1). An internal investigation revealed the Mail Order Pharmacy had mailed Patient 2 a medication bottle labeled and intended for Patient 1.During an interview on 7/25/14 at 10:35 a.m., the ethics and compliance officer (ECO) stated Patient 2 had received 2 packages via mail. Both packages had Patient 2's shipping label, but a medication bottle in one of the packages was intended for another patient (Patient 1).During an interview on 7/25/14 at 10:40 a.m., the compliance and privacy officer stated Patient 2 had taken two tablets of Patient 1's medication (Generic Tylenol with codeine #3 (Tylenol #3, a narcotic combination medicine used to relieve moderate to severe pain)).During an interview on 7/29/14 at 3:30 p.m., the pharmacy supervisor (PS) stated Patient 2 received two packages in the mail. One of the packages had a bottle of medication labeled for Patient 1, which was sent in error. PS further stated Patient 2 opened Patient 1's medication and took two tablets. PS stated Patient 2 had informed her he had taken Patient 1's medication knowing the medication belonged to another patient. The hospital did not retrieve Patient 1's medication from Patient 2.A review of a copy of a letter sent on 5/22/13 from the hospital to Patient 1 indicated the mail order pharmacy had accidentally sent Patient 1's medication to Patient 2.A review of the hospital's 12/2011 "Mail-Order Shipping Execution/Delivery Confirmation Tracking" 12/2011 policy indicated, double check and match the patient's name on the shipping label and the name on the prescription label before sealing the package. Affix a 2nd label (shipping label), to the package, right next to the 1st label (packaging label) so the names on both labels can be compared for matching.
Outcome:
Deficiency cited by the California Department of Public Health: Pharmaceutical Service General Requirements