VA Southwest Health Care Network (VISN 18)

Report ID: SPE000000074956, U.S. Department of Veterans Affairs

Reported Entity: VISN 18 Phoenix, AZ

Issue:

Today, 05/02/12, the Pharmacy supervisor notified the Privacy Officer (PO) that a controlled medication Schedule II prescription was provided to Veteran B but was intended for Veteran A. This occurred yesterday, 05/01/12, when the medication was provided to Veteran B at the on-station Pharmacy window. Veteran B should have received a different controlled medication. The dispensing error was discovered today when Veteran A presented to the Pharmacy for medication pickup, which had already been signed for. ACTIONS:1)Veteran As Rx was reprocessed and issued without interruption of medication. 2)The Pharmacy called Veteran B, who was not at home; return message left with roommate. recovery of medication pending. 3)Initial root cause: Staff failure to follow dispensing protocol. Both Veterans had a similar last name. Repeat staff error. Consultation with Human Resources (HR) pending. Removal of staff from Pharmacy dispensing window, in progress.4) Further notification and investigation, pending. Update: 05/02/12:Veteran A will be sent a notification letter.

Outcome:

Pharmacy notified clinic that Veteran did not receive medications, referral to them requested upon presentation. Further address Veteran address verification upon presentation requested in CPRS. Root cause was identified as human error in Pharmacy processing. Repeat error. Employee removing from dispensing window. Appropriate employee actions in progress along with focused employee privacy re-education by Supervisor.

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: SPE000000074968