SANTA CLARA VALLEY MEDICAL CENTER

Report ID: RD9011.02, California Department of Public Health

Reported Entity: SANTA CLARA VALLEY MEDICAL CENTER

Issue:

Based on interview and record review, the hospital failed to implement a procedure to prevent unauthorized access to one patient's (Patient 1) medical information. Findings:On 12/19/12, the California Department of Public Health received a faxed report from the hospital compliance officer which indicated the hospital identified accidental access to Patient 1's health information. During an interview on 8/28/13 at 11:30 a.m., the assistant director of pharmacy stated on 12/13/12, Patient 1's family member requested a refill of Patient 1's medication and brought in an old prescription bottle with Patient 1's name, medical record number, date of birth type of medication and physician's name.The director of pharmacy stated Patient 1's family member received the refilled medication and left the pharmacy.Later that day Patient 2's representative came in to pick up a prescription. The director of pharmacy stated the prescription bottle was electronically scanned and signed for. The next day Patient 2's representative returned to the pharmacy with Patient 1's old prescription bottle and had not received the prescription meant for Patient 2.During an interview on 9/5/13 at 2:00 p.m., the pharmacy clerk who assisted both representatives of Patients 1 and 2 stated Patient 1's representative had requested a refill for Patient 1 and gave the clerk an old prescription bottle to scan. The clerk stated she handed the bottle back, filled the prescription and Patient 1's representative left the pharmacy.The pharmacy clerk stated she assisted Patient 2's representative at the next counter. The pharmacy clerk stated she scanned the prescription and obtained the representative's signature and did not recall seeing any additional prescription bottles on the counter.The pharmacy clerk stated the next day Patient 2's representative returned to the pharmacy with Patient 1's old prescription bottle and the pharmacy clerk found Patient 2's prescription bottles on the pharmacy shelf.The pharmacy clerk was unable to determine how Patient 2's representative obtained Patient 1's old prescription bottle and did not receive the prescription intended for Patient 2. The pharmacy clerk stated the prescription label information included Patient's name, date of birth, medical record number, type of medication and physician's name.Record review on 9/5/13 at 3:00 p.m., of the hospital policy and procedure "Prescription Pick Up: Confirm pick-up status of each prescription on the computer."

Outcome:

Deficiency cited by the California Department of Public Health: Pharmaceutical Service General Requirements

Related Reports:

The report containing this deficiency also includes information about 1 other violation. Note that these may be related to the same event: RD9011.01

1 other violation reported on the same date. Note that other citations may be about the same event: YLB611.01