SANTA CLARA VALLEY MEDICAL CENTER

Report ID: EGUY11.01, 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 disclosure of a patient's health information (PHI) to an unauthorized individual, for one of two sampled patients (1), when upon medication pick-up, the hospital affiliated pharmacy (HAP) gave Patient 2, the two medications which belonged to Patient 1. The failure resulted in the disclosure of Patient 1's PHI to an unauthorized individual. Findings:The California Department of Public Health received a faxed report on 4/23/13, which indicated Patient 1 went to the HAP to pick-up her medication. At that time, it was discovered a pharmacy technician (PT) had inadvertently given Patient 1's medication to Patient 2. The pharmacy staff contacted Patient 2 to return the medication which had been given to her in error.During an interview on 6/24/14 at 10 a.m., the ethics and compliance officer (ECO) stated PT accidentally gave Patient 1's medication to Patient 2. The pharmacy called Patient 2 to return Patient 1's medication. The label on the medication displayed Patient 1's name, medical record number, account number (used for billing purposes), gender, and medication.During an interview on 6/24/14 at 11 a.m., the pharmacy assistant director (PAD) stated, Patient 2 went to the HAP to check if the HAP staff had received her doctor's faxed prescription order. When Patient 2 arrived at the "drop-off" window, she had been issued a patient's claim check. A hospital staff attached the other half of the claim check to the wrong prescription fax. Patient 2 went to the pick-up window with her claim check and was handed the prescription which corresponded to the number on the claim check. PAD then stated, at a later time, Patient 1 came to HAP to pick-up his prescriptions. During this time, the HAP staff realized Patient 1's medications were given to the wrong patient (Patient 2). When Patient 2 returned to the HAP, with the wrong medications, it was discovered who had received Patient 1's medications. During a telephone interview on 6/24/14 at 12:15 p.m., PT stated he gave Patient 2 her medication prescription based on the claim check number, and not her identity. PT stated the name on the claim check was of Asian descent, and so was Patient 2, therefore did not ask Patient 2 for another form of ID. PT further stated, "It was my fault, I should have asked for another ID."Although the hospital made an initial attempt to notify Patient 1 of the disclosure of PHI on 4/23/13, an official letter was sent to Patient 1 on 6/25/14. A review of a copy of a letter sent on 6/25/14, from the hospital to Patient 1, indicated atient 1's medical information had been accidentally disclosed to another patient when Patient 1's medication was given to Patient 2. The date the error was discovered was 4/4/13. The PHI disclosed included Patient 1's name, medical record number, account number, gender, and type of medication.

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 4 other violations. Note that these may be related to the same event: EGUY11.02, EGUY11.03, EGUY11.04, EGUY11.05

3 other violations reported on the same date. Note that other citations may be about the same event: CRM711.01, CRM711.02, ITGS11.01