VA Southwest Health Care Network (VISN 18)

Report ID: SPE000000074257, U.S. Department of Veterans Affairs

Reported Entity: VISN 18 El Paso, TX

Issue:

Veteran A reported to the facility Privacy Officer that he received pharmacy insert information included with his mailed prescription to his home address. The pharmacy insert included in Veteran A's packet included prescription information and included the full name of Veteran B, mailing address, name of medication, name of physician, and condition/diagnosis for which drug prescribed as well as listing of other medications prescribed for Veteran B. All information was returned to the Privacy Officer. Update: 04/17/12:Veteran B will be sent a notification letter due to personal health information being disclosed.

Outcome:

Update per Chief, Pharmacy as follows: 04/19/2012: Findings: Fact finding and review of incident determined that - Veteran A received his Rx in the mail for drug X which was checked by Staff RPh #6. The person that prepared the Rx for mailing is unknown since the patient disposed of the mailing envelope. - Along with the paperwork for drug X, the package also contained paperwork for drug Y for Veteran B. Only the paperwork (drug Y label), not the medication was in the package. The following corrective action was implemented to address this issues and to assure that this type of error does not recur: All of Pharmacy techs/volunteers who package prescriptions for mailing have been issued unique rubber stamps for stamping on the address labels. There is a "key" posted on the bulletin board in the mailing area that lists the names and corresponding rubber stamp for each employee. Pharmacists may also request a rubber stamp if they choose to use it on Rx labels in lieu of their initials - A visual sign will be posted on the counter top in the mailing area to remind employees to stamp (or initial) every address label that is affixed to each package. - Effective immediately, all employees that package mail-outs will be required to thumb through the stack of handouts for patients receiving multiple items and circle, stamp over, or initial by the patient's name on each cover sheet to verify that all handouts (and medications) are for the correct patient. Any irregularities will immediately be brought to the attention of a pharmacist. Developed new signage for mail-out area in Pharmacy; the posted signs will also include the above new procedure. Notice received per NSOC for required notification to affected Veteran B informing patient of error in mailing of drug insert information. Copy of redacted letter of notification prepared for new Interim Director signature and uploading to this ticket as required. Ticket recommended for closure upon uploading of redacted notification letter provided to Veteran B. Submitted: JWinstead, Privacy Officer EPVAHCS