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 Southwest Health Care Network (VISN 18)

VISN 18 Phoenix, AZ

Mentioned in a privacy incident report created by the U.S. Department of Veterans Affairs on January 28, 2013. Also cited in 228 other reports.


Report ID: PSETS0000085122, U.S. Department of Veterans Affairs

Reported Entity: VISN 18 Phoenix, AZ

Issue:

On 1/28/2013, The Pharmacy Supervisor reported to the Privacy Officer (PO) that Veteran B received antibiotics meant for Veteran A at the outpatient pharmacy window on 1/25/2013. This was discovered by the pharmacy technician who could not find medications for Veteran A when requested for pickup. Veteran As medications were reprocessed and dispensed. Phone calls on 1/25/2013 and again 1/28/2013 to Veteran B to initiate medication recovery have not been returned. Mitigation efforts by Pharmacy continue. Contributory factors identified: Veteran B picked up 20 prescriptions at once. Both Veterans have the same last name; both are female. Additional notification and investigation to ensue. Update: 01/28/13:Veteran B will be sent a HIPAA notification letter.

Outcome:

Medications and rx education materials were recovered by Pharmacy. A change in workload, reassignment and re-education was performed by the Pharmacy supervisor regarding Veteran identity when dispensing medications. Pharmacy Chief is also working on another automatic Veteran identity matching program to reduce human errors. HIPAA notification letter mailed to Veteran. Investigation concluded.

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