SANTA CLARA VALLEY MEDICAL CENTER

Report ID: CRM711.01, 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's health information (PHI) for one of two sampled patients (2), when a medication was incorrectly mailed. The failure resulted in the disclosure of Patient 2's PHI to an unauthorized individual. Findings:The California Department of Public Health received a faxed report on 3/28/13 which indicated on 3/25/13 Patient 1 brought to the pharmacy a vial of insulin (medication used to control blood sugar) which had Patient 2's name on it. Patient 1 stated she had received the vial by mail in January 2013, but did not realize the insulin vial did not belong to her. She had kept this vial in her refrigerator since she had received it in January. On 3/24/13, Patient 1 went to use the insulin, and realized the insulin vial belonged to another patient. Patient 1 brought the vial to the pharmacy to report the error.During an interview on 6/24/14 at 11:40 a.m., the pharmacy supervisor (PS) stated, Patient 1 had brought a bottle of insulin to the hospital's outpatient pharmacy. Patient 1 informed the staff the insulin was for another patient. PS then stated, Patient 1 received the insulin in January 2013. Patient 1 did not question why she had received the insulin without ordering it, and just put it in her refrigerator. PS also stated, Patient 1 had not kept the mailing package. PS further stated, Patient 1 did not look at the mailing label, and just opened the package and put the insulin in the refrigerator. A review on 6/24/14, of a copy of the label from the insulin Patient 1 had returned to the pharmacy, indicated Patient 2's name, medication information, and medication dosage were disclosed. A review of a copy of a letter, dated 3/28/13, which the hospital sent to Patient 2 indicated Patient 1 had been mailed medication, from the Mail Order Pharmacy, which had been identified as belonging to Patient 2. The information which accompanied the medication included some or all of the following: Patient 2's name, home address, medical record number, insurance, and medication and dosage information.

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: CRM711.02

6 other violations reported on the same date. Note that other citations may be about the same event: EGUY11.01, EGUY11.02, EGUY11.03, EGUY11.04, EGUY11.05, ITGS11.01