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)

VISN 18 Phoenix, AZ

Mentioned in a privacy incident report created by the U.S. Department of Veterans Affairs on March 11, 2013. Also cited in 228 other reports.


Report ID: PSETS0000086626, U.S. Department of Veterans Affairs

Reported Entity: VISN 18 Phoenix, AZ

Issue:

Today, 3/11/2013, pharmacy Supervisor reported that Veteran B received an injectable drug for Veteran A by mail in addition to his own medication. Veteran A's first name, last name, drug, physician, and address on bottle were exposed. The medication was returned to the Pharmacy today by Veteran B in person. No additional materials were mailed. The Pharmacy notified Veteran A and mailed a refill. Preliminary root cause was failure to follow Veteran identity protocol when mailing medication. Corrective departmental actions in place is formal Veteran identity checking procedure and medication dispensing check list circulating for editing then approval, short implementation cycle Update: 03/12/13:Veteran A will be sent a notification letter.

Outcome:

The root cause of failure to follow Rx bagging and Veteran identity matching protocols in the Pharmacy was identified. A new SOP has been developed for ID matching with employee in-service. Additional one-on-one education in the Pharmacy was conducted. Veteran notification letter signed and mailed 3/20/2013. Case concluded.

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