SANTA CLARA VALLEY MEDICAL CENTER

Report ID: 7Z8R11.01, California Department of Public Health

Reported Entity: SANTA CLARA VALLEY MEDICAL CENTER

Issue:

Based on interview and record review, the hospital failed to prevent the unauthorized disclosure of patient health information (PHI) for one of two sampled patients (1), when the pharmacy mailed a package containing Patient 1's medication to the wrong patient (2). The failure resulted in the disclosure of Patient 1's PHI to an unauthorized individual. Findings:The California Department of Public Health received a faxed report on 5/22/13, which indicated on 5/17/13, Patient 2 had received two packages in the mail, both addressed to him. Both packages contained medications, but one of the packages had a medication which was labeled for Patient 1. The hospital's internal investigation determined both packages had Patient 2's mailing address, but one of the packages contained a medication which was intended for Patient 1.During an interview on 7/25/14 at 10:35 a.m., the ethics and compliance officer (ECO) stated Patient 2 received two packages in the mail, both addressed to him. After Patient 2 had opened both packages, he noticed one of the medication bottles was labeled with Patient 1's information. Patient 2 called the hospital pharmacy to notify staff he had received a medication with another patient's information on the label.During an interview on 7/25/14 at 10:40 a.m., the pharmacy director (PD) stated a pharmacy mail technician placed a mailing label over the packing label. PD further stated the technician was supposed to compare the packing label to the mailing label, to make sure they matched, but the technician probably did not.During an interview on 7/25/14 at 12 p.m., the pharmacy technician stated he was not sure if he placed the wrong mailing label on the package.During an interview on 7/29/14 at 3:30 p.m., the pharmacy supervisor (PS) stated Patient 2 received two packages. One of the packages had a medication bottle labeled for Patient 1, which had been mailed in error. PS stated she believed Patient 2's mailing label was printed twice and was inadvertently placed on both packages. PS stated she believed Patient 1's mailing label did not get printed. PS further stated the medication label disclosed Patient 1's name, medication, prescription number, and dosage.A review of a copy of the label which was placed on Patient 1's medication bottle, indicated Patient 1's name, medication, dosage, and prescription number had been disclosed to Patient 2.A review of a copy of a letter sent on 5/22/13, from the hospital to Patient 1, indicated Patient 1's medical information was accidentally disclosed when the mail order pharmacy had accidentally mailed her medication to another patient (Patient 2). The letter further indicated Patient 1's name, medical record number, insurance plan, home address, and prescription information had been disclosed.A review of the hospital's 12/2011 "Mail-Order Shipping Execution/Delivery Confirmation Tracking" policy indicated, double check and match the patient's name on the shipping label and the name on the prescription label before sealing the package. Affix a 2nd label, with address and postage, right next to the 1st label, on the package, so the names on both labels could be compared for matching.

Outcome:

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

Related Reports:

The report containing this deficiency also includes information about 1 other violation. Note that these may be related to the same event: 7Z8R11.02

3 other violations reported on the same date. Note that other citations may be about the same event: 191292, DHZ011.01, URRF11.01