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.
VA Healthcare - VISN 4 (VISN 4)
Mentioned in a privacy incident report created by the U.S. Department of Veterans Affairs on December 20, 2012. Also cited in 239 other reports.
Report ID: PSETS0000083948, U.S. Department of Veterans Affairs
Reported Entity: VISN 04 Butler, PA
Issue:
On 12/20/12, Veteran A, who resides in the Domiciliary (DOM), opened up his medication bag and found medication for Veteran B, who also resides in the Domicilary, in his bag. The medication was actually picked up from the pharmacy on 12/13/12. The DOM Nurse notified the Pharmacy of the mix up. The Pharmacy supervisor notified the Information Security Officer (ISO) and Privacy Officer (PO) of the incident on 12/20/12 at 12:55 PM. Both patients prescriptions were processed through within 17 minutes of each other, checked within 1 minute of each other, and were flagged as Domiciliary orders. Pharmacy Supervisor believe the similarity in names, timeframe, Domiciliary label, and the quantity of prescriptions were contributing factors in this error. Update: 12/20/12:Veteran B will be sent a letter of notification.
Outcome:
Butler Pharmacy will no longer be allowing staff to add prescriptions to existing batches. The ScriptPro system has a flaw that will allow 2 patients to be combined in a batch. This also extends to adding controlled substance scripts to the rest of a Veterans orders. The control will be batched separately from the rest of the meds