VA Health Care Upstate New York (VISN 2)

Report ID: SPE000000078956, U.S. Department of Veterans Affairs

Reported Entity: VISN 02 Syracuse, NY

Issue:

The Outpatient Pharmacy Supervisor reported that there was a delivery error where Patient A received Patient B's prescription with his order. Patient B's prescription was sent in error with two correct prescriptions for Patient A. These were Scriptalk orders which are the talking labels that appear different. The only sensitive information on these prescription labels is name and drug information. The order was processed through the second check protocol by two student pharmacy technicians and a pharmacist who checks the final order but all three employees missed that there were two patients' orders mixed into one. The pharmacy has sent Patient A a postage paid envelope to return the prescription he received in error and has sent Patient B his medication. The Outpatient Pharmacy Supervisor discussed the error with all three employees were to so they are aware to slow down and be more careful in order to prevent future errors. Update: 08/09/12:Patient B will be sent a letter of notification.

Outcome:

Outpatient Pharmacy Supervisor confirmed receipt of medication back from Patient A that he received in error. Pharmacist and pharmacy students involved in the wrapping process re-educated on the requirement to confirm 2 patient identifiers before wrapping the medications for mailing.

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: SPE000000078961