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 Southwest Health Care Network (VISN 18)
Mentioned in a privacy incident report created by the U.S. Department of Veterans Affairs on January 30, 2013. Also cited in 228 other reports.
Report ID: PSETS0000085243, U.S. Department of Veterans Affairs
Reported Entity: VISN 18 Phoenix, AZ
Issue:
Today, 1/30/13, the Pharmacy Supervisor reports that Veteran B returned 2 prescriptions to the Pharmacy which were intended for Veteran A. Veteran B was the ED last evening when he was dispensed an antibiotic and a steroid. At home, Veteran B realized this and did not ingest the medications. The medications and accompanying materials with Veteran A protected health information (PHI) were recovered. Copies will be provided to Privacy Officer (PO) to identify the scope of PHI exposure. The Pharmacy Supervisor\xe2\x80\x99s initial investigation shows no documentation of these medications in Veteran B\xe2\x80\x99s chart for 01/29/13 encounter but instead found documentation on Veteran A\xe2\x80\x99s chart for this date, time, and location showing medications dispensed. Before dispensing medications now to Veteran B, Pharmacy will identify which patients were in the ED, the symptoms, diagnosis, treatment, etc. Both patients have the same first name and almost the same last name. After hours, the Pharmacy provides medications to the ED where dispensing is performed. Pharmacy is addressing identity verification and documentation issues with ED as a first step. Additional after-hour coordination with ED will also be reviewed. The PO will alert Health Information Management Service (HIMS) regarding the possible need for chart documentation review/correction. Additional notification and investigation to ensue. Update: 01/30/13: Veteran A will be sent a notification letter. 05/16/13: This was determined to be non-HITECH reportable by VHA Privacy Office.
Outcome:
After hours processing has been adapted in the handoff from Pharmacy to the ED patients. Medical record documentation has also been reviewed and corrected by HIMS Chief. Staff involved were provided with additional pharmacy identification.