SUTTER SANTA ROSA REGIONAL HOSPITAL

Report ID: R66U11, California Department of Public Health

Reported Entity: SUTTER SANTA ROSA REGIONAL HOSPITAL

Issue:

Based on interview and record review, the facility failed to prevent unauthorized access and disclosure of a patient's (Patient 1) protected health information, when X-Ray results for Patient 1 were faxed to the Wrong Physician. This failure allowed the unlawful or unauthorized access to protected health information.Findings:The California Department of Public Health was notified on 9/19/13 that a, "Breach of Protected Health Information (PHI)", occurred on 9/8/13.During an interview on 9/30/13 at 2:15 p.m., Administrative Staff A stated that she received notification from IT Coordinator C, on 9/13/13, that he had received a phone call from the Wrong Physician's office indicating that the physician had been faxed PHI for Patient 1 in error. Administrative Staff A also stated that Unlicensed Staff B had entered the Wrong Physician as the ordering physician instead of Patient 1's Physician, therefore the X-Ray results had been sent to the Wrong Physician. The PHI included Patient 1's: name, date of birth, medical record number, phone number, procedure, and X-Ray results.Administrative Staff A further stated that it was an error on the part of Unlicensed Staff B, in that both physicians had the same last names.A review of the facility Policy and Procedure for, "FACSIMILE (FAX) TRANSMISSION OF MEDICAL RECORDS", (7/12), reveals the following: "I. POLICY The sensitive information contained in health records may be transmitted via facsimile (fax) when delivery through the regular mail will not meet the requestors' or senders' needs, such as for patient care...II. PROCEDURE Faxing Protected Health Information (PHI):..6. Care should be taken to assure the fax transmission is sent to the appropriate destination. Destination numbers should be pre-programmed into the fax machine, if possible, to eliminate errors in transmission from misdialing. The fax number on the screen of the fax machine should be checked to be sure it is correct prior to pressing the "send" button".A review of the facility Policy and Procedure for, "Workforce Confidentiality/Privacy and Appropriate Use of Facility Property", (no date), reveals the following: "C. Access and Use of Patient and Business Information...3. Workforce members are expected to adhere to the following guidelines in order to maintain security and confidentiality: a. Ensure recipients of confidential information are authorized to receive it. Verify identities of recipients before releasing any information".A review of the facility Policy and Procedure for, "Confidentiality of Patient Care Information", (10/10), reveals the following: "I. POLICY Persons receiving health care services have the right to expect that the confidentiality of individually identifiable medical information will be reasonably preserved. Information regarding the hospital's patients' medical or personal status will not be released or disclosed inappropriately...III. APPLICATION OF POLICY A. All patient-related information is confidential. It will be shared only with those persons that have a legal right (i.e. the patient or the patient's surrogate) or a legitimate work-related need to know".

Outcome:

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