MARIN GENERAL HOSPITAL

Report ID: 035I11.01, California Department of Public Health

Reported Entity: MARIN GENERAL HOSPITAL

Issue:

Based on staff interviews, clinical record and administrative document review, the hospital failed to ensure unauthorized access of personal and patient health information when Patient 1's Magnetic Resonance Imaging (MRI) report was sent to the wrong physician when it was attached to another patient's file. This resulted in a breach of personal and patient health information and possible unauthorized use.Findings:During an interview on 7/2/12, the Director of Compliance and Ethics stated that the error occurred when the record for Patient 1 was inadvertently included in the record for another patient and then sent to the second patient's physician.The information disclosed with that record included Patient 1's name, birth date, medical record number and results of the MRI.The procedure for processing this information involves a system that allows only the specific radiologist to dictate the information and using voice recognition rather than a dictating machine. The reports are automatically recorded and then transcribed by the transcriptionist. In this case there were two reports to be transcribed and the transcriptionist failed to close the first report before entering the second report. This resulted in both reports being sent to the wrong physician. The facility does not have a written protocol describing how the reports should be handled, specifically in regard to assuring one is closed prior to a second report being transcribed.

Outcome:

Deficiency cited by the California Department of Public Health: Health & Safety Code 1280

Related Reports:

5 other violations reported on the same date. Note that other citations may be about the same event: HXO011.01, LNW711.01, Q57Y11.01, RFU211.01, U3ES11.01