VA Health Care Upstate New York (VISN 2)

Report ID: PSETS0000086041, U.S. Department of Veterans Affairs

Reported Entity: VISN 02 Syracuse, NY

Issue:

Patient A and Patient B were sent each others insulin. After it was investigated by the Outpatient Pharmacist Supervisor, it was discovered the medication coolers were addressed prior to the medication being checked by the Pharmacist. The Technician packed the drugs for delivery in the wrong coolers. This resulted in Patient A's name, address, and medication information being inappropriately disclosed to Patient B and vice versa. Both patients have been contacted and Patient A has returned Patient B's insulin. The Outpatient Pharmacy has sent a pre-paid mailer to Patient B for return of Patient A's medication. No medication was used in error. The Outpatient Pharmacy department has been educated to have the Pharmacist check the completed prescription including the shipping cooler to verify the shipping address before mailed to prevent future errors. Update: 02/22/13:Both Patients will be sent HIPAA letters of notification.

Outcome:

The Outpatient Pharmacist has educated the technicians and Pharmacists regarding the new requirement to have the Pharmacist check the completed prescription including the shipping cooler to verify patient identifiers before mailing.

Related Reports:

1 other violation reported on the same date. Note that other citations may be about the same event: PSETS0000086047