SANTA CLARA VALLEY MEDICAL CENTER

Report ID: CKZM11.01, California Department of Public Health

Reported Entity: SANTA CLARA VALLEY MEDICAL CENTER

Issue:

Based on interview and record review, the hospital failed to prevent the unauthorized disclosure of patient health information (PHI) for one of two sampled patients (1), when Patient 1's medication was mailed to Patient 2. The failure resulted in the disclosure of PHI to an unauthorized individual. Findings:The California Department of Public Health received a faxed report on 8/22/13, which indicated Patient 2 returned three medication bottles to the hospital affiliated pharmacy on 8/19/13. The medications were prescribed for Patient 1. The hospital's internal investigation revealed Patient 1's address may not have been verified prior to mailing his medication. Patient 2, who received Patient 1's medication, had the same first and last name as Patient 1 with the exception of a middle name. The label on the medication bottles disclosed Patient 1's name, medication name, medication directions, and medical record number.During an interview on 8/20/14 at 2:15 p.m., the pharmacy director (PD) stated Patient 2 had received Patient 1's medication in the mail. Patient 2 returned the incorrect medications to hospital affiliated pharmacy A (Pharmacy A) on 8/19/13 and stated his doctor had not ordered those medications. PD stated Patient 2 had not taken any of the medication. PD stated, on 8/17/13, Patient 1 went to hospital affiliated pharmacy B (Pharmacy B) and told the pharmacy staff he had not received his medications which he had ordered. The pharmacy staff noticed the mail order records indicated Patient 1's medications had been mailed to him, so the pharmacy staff had assumed the medications had been lost in the mail. During a telephone interview on 8/26/14 at 3 p.m., the pharmacist in charge (PCS) of Pharmacy B stated in 08/2013, Patient 2 brought to Pharmacy A a package with the three medications, which had been mailed to him, and stated they were not his medications. PCS stated Patient 2's name was on the medication label. PCS then stated the package had Patient 2's name and address, but the medications in the package were not Patient 2's medications. PCS stated, during the pharmacy's internal investigation, it was determined the three medication bottles belonged to Patient 1. PCS stated both Patient 1 and Patient 2 had very similar names. During a telephone interview on 8/26/14 at 3 p.m., the pharmacy technician (PT) who had been working at Pharmacy A, stated Patient 2 walked into the pharmacy with the three medication bottles and stated those medications were not his medications. PT stated Patient 2 handed the incorrect medications to her in the mail order package then walked out of the pharmacy before she had a chance to ask him any questions. A review of a copy of a letter dated 8/22/13, from the hospital to Patient 1, indicated on 8/19/13, Pharmacy A staff were notified that Patient 2 had inadvertently received Patient 1's medication. The label on the medication bottles disclosed Patient 1's name, medication name, medication directions, and medical record number. An internal investigation by the hospital revealed the pharmacy had an incorrect mailing address for Patient 1, and Patient 1's medication was inadvertently mailed to the incorrect address.

Outcome:

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

Related Reports:

The report containing this deficiency also includes information about 1 other violation. Note that these may be related to the same event: CKZM11.02

3 other violations reported on the same date. Note that other citations may be about the same event: 7RWF11.01, 7RWF11.02, 80V211.01