LOMA LINDA UNIVERSITY MEDICAL CENTER

Report ID: UBFE11.01, California Department of Public Health

Reported Entity: LOMA LINDA UNIVERSITY MEDICAL CENTER, TRANSPLANT I

Issue:

Based on interview, and record review, the facility failed to ensure a transplant assistant verified the names on documents before stapling them together. This failure resulted in Patient A's confidential, protected, health information (PHI) being stapled to Patient B's documents, placing Patient A at risk for identity theft, and had the potential for the misuse of Patient A's PHI by unauthorized users.Findings;On May 6, 2014 at 10:20 AM, a phone interview was conducted with the Compliance Officer regarding an entity reported incident of a breach of PHI for Patient A. The Compliance Officer stated, "Employee 1 was doing multiple orders and did not verify that the laboratory request form she was stapling to a packet for Patient B, contained Patient B's name. This resulted in Patient A's laboratory slip being stapled to Patient B's forms. Patient B noted the error, and immediately returned the forms to the unit, and attested that no information had been copied. Employee 1 [who was unavailable for interview] was counseled and re-educated on the privacy rules."On May 9, 2014 at 8:30 AM, a review of the document that had been provided to Patient B in error was conducted. The document contained Patient A's name, medical record number, date of birth, diagnoses and a list of laboratory tests to be done. The failure to ensure that the document contained the correct patient's name, resulted in Patient A's PHI being released without authorization to Patient B.

Outcome:

Deficiency cited by the California Department of Public Health: Patients' Rights

Related Reports:

2 other violations reported on the same date. Note that other citations may be about the same event: 98F011.01, TL4D11.01