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 Southwest Health Care Network (VISN 18)
Mentioned in a privacy incident report created by the U.S. Department of Veterans Affairs on October 25, 2011. Also cited in 228 other reports.
Report ID: SPE000000067999, U.S. Department of Veterans Affairs
Reported Entity: VISN 18 Phoenix, AZ
Issue:
Today, 10/24/11, at 4 PM, the Pharmacy supervisor reported to the Privacy Officer (PO) that Veteran A was discharged earlier today with 4 medications for Veteran B. Upon arriving home, Veteran A reported this to the Pharmacy by phone. He did not ingest any of the medications and none of them were narcotics. Veteran B was also on the same unit with 5 medications upon discharge. Veteran A and Veteran B have similar sounding surnames. The missing prescription was presumed by the Veteran to be left in the restroom, post discharge. Discussion with Pharmacist, Charge Nurse and unit nurse ensued. Veteran Bs medications were reprocessed by clinical pharmacist. UPS overnight return packaging will go to Veteran A in the morning for recovery of medications and educational materials. Additional notification and investigation to ensue. Update: 10/31/11:Veteran B will receive a letter of notification.
Outcome:
Correct dispensing of RX education materials, verified with Pharmacy. Correct RX dispensing protocol was discussed by supervisor with LPN and RN. Both shifts were provided with education on medication reconciliation and also an additional protocol between shifts. Each employee was also individually counseled on patient safety and privacy ramifications.