VA Southwest Health Care Network (VISN 18)

Report ID: PSETS0000082285, U.S. Department of Veterans Affairs

Reported Entity: VISN 18 Phoenix, AZ

Issue:

Today, 11-13-2012, Pharmacy Supervisor reports to Privacy Officer (PO) that medication and one VA correspondence intended for Veteran A was sent by mail to Veteran B. Veteran B refused the medication. He had previously received another piece of correspondence Veteran A. At the time of the 1st mismailing, Veteran B had reported occurrence to the outpatient clinic of origin, by his report. Pharmacy Supervisor does not have the medication back by mail yet. She investigated Veteran As medication log to find that were 2 subsequent medications mailed to Veteran B for Veteran A in this same time frame. No exposure of medications/content to Veteran B.ACTION:1)Pharmacy Supervisor has identified root cause: 2 separate address changes by staff for Veteran A who also referenced Veteran Bs address.2)Veteran A was contacted by Pharmacy Supervisor. Address verification and system wide address correction performed.3)Medications were reissued and mailed to verified address for Veteran A.4)Recovery of medications in progress.Further investigation and notifications to ensue. Update: 11/13/12:Veteran A will be sent a notification letter.

Outcome:

Retrieval of both rx's with prompt re-issuance by Pharmacy; no interruption of service or patient care. Root cause: failure to follow Veteran identity protocols when dispensing medications. Re-education was provided to staff by Pharmacy Supervisor. Quality monitors in place. Investigation concluded. HIPAA notification to Veteran.