Scripps Mercy Hospital

Report ID: 1OPP11.03, California Department of Public Health

Reported Entity: SCRIPPS MERCY HOSPITAL

Issue:

Based on interview and record review, the hospital failed to safeguard protected health information (PHI- is any information about health status, provision of health care, or payment for health care that can be linked to a specific individual) from unauthorized person(s) in accordance with their policies and procedures, for 1 of 2 sampled patients (Patient 1). Patient 1's home medications were inadvertently given to the wrong patient at discharge.Findings:On 6/7/12 at 5:09 P.M., the hospital reported to the Department that an unauthorized disclosure of patient health information may have occurred when Patient 1's home medications were given to the wrong patient.A review of Patient 1's medical record was conducted on 10/18/12 at 8:15 A.M. Patient 1 was admitted to the hospital on 6/1/12 with a chief complaint of abdominal redness and swelling per the Discharge Summary, dated 6/3/12. Per the Discharge Summary, Patient 1 was discharged on 6/3/12.According to Patient 1's "Patient's Own Medications Envelope" (an inventory of the patient's home medications at admission), dated 6/1/12, the following medications were listed: Insulin (medication to treat high blood sugars) syringe, hydrocodone (used to treat moderate to severe pain), hydromorphone (also known as Dilaudid - a narcotic used to treat moderate to severe pain), Oxycodone (a narcotic pain reliever, used to treat severe pain), Quinapril (blood pressure medication), methotrexate (used to slow the growth of certain cells in the body), ketoprofren (nonsteroidal anti-inflammatory drug), Ferrous Sulfate (iron used to treat anemia), Citalopram (anti-depressant medication), Furosemide (used to treat edema), Folic Acid (vitamin supplement), multi-vitamins, Amiodarone (medication used for irregular heart beat), Bayer Aspirin (relieves pain and reduces fever), Vitamin D3, Prevacid (antacid- suppresses acid secretion in the stomach) and Prilosec (antacid). In addition, the Patient 1's label contained the following information (located on the top right hand corner of the Patient's Own Medication Envelope form): patient's name, medical record number, account number, date of birth and physician name.A review of Patient 2's medical record was conducted on 10/18/12, at 8:15 A.M. Patient 2 was admitted to the hospital on 5/31/12, with a chief complaint of respiratory distress per the Discharge Summary, dated 6/2/12. Per the Discharge Summary, Patient 2 was discharged on 6/2/12.A review of the hospital's policy entitled "Medications: Orders, Administration, and Documentation," effective date of 2/2012, was conducted. The policy indicated patient's own medications will be inventoried on the "Patient's Own Medication Envelope" and returned to the patient at the time of discharge.A review of the hospital's policy and procedure entitled "Health Information, Access, Use and Disclosures," effective date of 2/12, was conducted. The policy indicated that the hospital shall access use and disclose protected health information with authorization of patient/legal representatives and in accordance with mandated state and federal disclosure requirements. Per the same policy, it indicated that "All personnel providing services within the (hospital name) organization to include but not limited to employees, volunteers, physicians, Allied Health Professionals, students and contracted and affiliated business associates are responsible for: 1. Awareness of this policy and it's requirements for protecting patient health information from unauthorized access, use or disclosure." An interview with technical partner (TP 1) was conducted on 11/8/12 at 3:10 P.M. TP 1 stated that she assisted with the discharge of Patient 2. She stated that she picked up Patient 2's home medications from the pharmacy on 6/2/12, but did not verify that the home medications given to her by the pharmacy technician belonged to Patient 2. She stated that she handed the bag of home medications to Patient 2 without ensuring that the home medications belonged to Patient 2.An interview and joint record review with the 6th Floor Manager was conducted 11/20/12 at 2:04 P.M. The 6th Floor Manager acknowledged that TP 1 should have followed the hospital's policy to ensure that the correct home medications were given to the right patient at discharge. She acknowledged that an unauthorized disclosure of confidential patient information occurred when Patient 1's home medications were inadvertently given to Patient 2 on 6/2/12.

Outcome:

Deficiency cited by the California Department of Public Health: Patients' Rights

Related Reports:

The report containing this deficiency also includes information about 3 other violations. Note that these may be related to the same event: 1OPP11.01, 1OPP11.02, 1OPP11.04

1 other violation reported on the same date. Note that other citations may be about the same event: GZZK11.01