Search Privacy Violations, Breaches and Complaints
This database was last updated in December 2015 ago and should only be used as a historical snapshot. More recent data on breaches affecting 500 or more people is available at the U.S. Department of Health and Human Services’ Breach Portal.
VA Mid South Healthcare Network (VISN 9)
Mentioned in a privacy incident report created by the U.S. Department of Veterans Affairs on September 29, 2011. Also cited in 328 other reports.
Report ID: SPE000000067274, U.S. Department of Veterans Affairs
Reported Entity: VISN 09 Nashville, TN
Issue:
On 09/28/11, Veteran A presented to the Outpatient Pharmacy (Nashville Campus) to retrieve his five medications and was also dispensed two medications which belonged to Veteran B. The error was noted later in the day when Veteran B presented to Outpatient Pharmacy to retrieve his medications.Upon investigation, the pharmacy tech found that Veteran A and B have the same first name, last name, but a different middle initial. Veteran A and Bs medications were side by side on the shelf. When retrieving Veteran As medications, the pharmacy tech also retrieved Veteran Bs. The pharmacy tech did not visually check the address and date of birth label on all bags to confirm correctness. The pharmacy tech scanned the medication bags through Script Pro and it changed Veteran Bs address to that of Veteran A. The pharmacy tech did not notice the change. Veteran Bs medications were dispensed at the window. The Outpatient Pharmacy Supervisor (Nashville Campus) contacted Veteran A at home and confirmed he received Veteran Bs medications. Arrangements were made for Veteran A to return Veteran Bs medications via UPS. Veteran Bs Personal Identifiable Information (PII) disclosed: Full name, address, date of birth, and names of medications. Update: 09/29/11:Veteran B will be sent a letter of notification.
Outcome:
UPS envelope containing the meds given to wrong Veteran have been returned to the pharmacy and destroyed. The pharmacy tech did not follow correct procedure for obtaining proper ID before dispensing the medication. Employee was counseling regarding the importance of following correct procedure.