RIVERSIDE COUNTY REGIONAL MEDICAL CENTER

Report ID: Y54411, California Department of Public Health

Reported Entity: RIVERSIDE COUNTY REGIONAL MEDICAL CENTER

Issue:

Based on staff interview and record review, the facility failed to prevent the unauthorized access and/or disclosure of Patient A's private health information (PHI), when Patient (Patient B) received Patient A's filled prescriptions. This facility failure had the potential to result in the misuse of Patient A's medication, breach of medical information, harm for Patient B who took the wrong medications, and up to and including patient hospitalization, and or death.Findings:An interview was conducted with the Admissions Service Officer (ASO) on August 13, 2015, at 8 a.m. The ASO stated Patient B's spouse came to the facility pharmacy to pick up a prescription. The wrong medications were given to the spouse, but were checked off as correct by the Pharmacy Technician and Pharmacist. The medications were taken home by the spouse and given to the Patient B, not the patient for whom the medications were intended. Patient B took the following wrong medications: Ibuprofen 600 milligrams (mg) (mild pain reliever) and Azithromycin 250 mg (an antibiotic). When Patient B saw there was an inhaler (Proair) included in the bag of medications, she looked at the prescription label, saw it did not match her name, and brought all the medications back to the pharmacy.The ASO stated the correct procedure for the technicians and the pharmacist is to compare at a minimum two patient identifiers to match the prescription. (Patient identifiers include patient identification such as a driver's license and a verbal statement of the patient name before signing off on the release of the medication). In addition, the pharmacist was not to sign off on the release the medication until he or she completed their own identification check, which included personal identification and verbalization of the patient name. The ASO stated both the pharmacy technician and pharmacist failed to follow the facility policy on patient identification. The ASO stated Patient B denied any adverse side effects or reactions to taking the wrong medicationsDuring a record review completed on August 8, 2015, Patient A's and Patient B's names were reviewed. The two names were not similar in spelling or pronunciation, but were of Spanish origin. Patient A was sent a letter dated August 12, 2015, which indicated the facility had a recent, "unintended disclosure of patient information." The letter indicated,"On July 30, 2015, the (facility) Privacy Office was made aware that your prescription medication was...provided to another patient. The educational document that was included with the medication disclosed your name, date of birth, home address, home telephone number, and the name of the medications prescribed to you..."The facility policy titled, "Outpatient Product Quality and Safety Concerns," revised February 2014, indicated; "Delivery/Providing of Prescription and Counseling the Patient (Out Window),...The patient's receipt will be matched with paperwork in the bag (use the double check method, name and receipt number) A three step identification process will be used. The patient/patient representative at the window will be asked to confirm the following:Patient name, andPatient date of birth, andPatient address, and/orPicture identification (government issued preferably) will be utilized for prescription pick-up, of both the person receiving the prescription and the patient, if these differ.If any of the above elements cannot be verified, additional efforts may be made utilizing: phone number, social security number, or medical record number.The contents of bag (filled prescription) will be placed onto the counter and verification of the paperwork, prescriptions and vials will be done to ensure these are for the correct patient."

Outcome:

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