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.
SHARP CHULA VISTA MEDICAL CENTER
Cited by the California Department of Public Health for a violation of California’s Health and Safety Code relating to medical privacy during an inspection that began on October 8, 2013. Also cited in 46 other reports.
Report ID: VSX011.01, California Department of Public Health
Reported Entity: SHARP CHULA VISTA MEDICAL CENTER
Issue:
Based on interview and document review, the hospital failed to ensure that personal and protected health information (PHI) was safeguarded for 1 of 2 sampled patients (2). Patient 2 was discharged from the hospital with Patient 1's written medication prescription instead of Patient 2's own prescription. Patient 2's husband discovered the error and brought it to the hospital's attention. Patient 2's physician had to write the correct prescription for Patient 2 to pick up. As a result of this failure, Patient 2 had access to Patient 1's personal information listed on the written prescription. Findings:A review of Patient 2's medical record was conducted with the women's services nurse manager (WSNM) on 10/8/13 at 3:30 P.M. Patient 2 was discharged from the hospital on 9/21/13, per the hospital's Facesheet. Patient 2's Discharge Summary (patient's hospital summary, discharge medications and plan, signed by the physician) dated 9/21/13, indicated the physician prescribed Tylenol 3 (pain medication). The medication section of Patient 2's Depart Summary (patient's copy of discharge medications and plan transcribed per physician's order, signed by the patient and RN) dated 9/21/13, did not indicate the physician's prescribed Tylenol 3 (pain medication). In addition, the Depart Summary was signed by Patient 2 and Registered Nurse (RN) 2. An interview was conducted with RN 1 on 10/8/13 at 4:20 P.M. RN 1 stated that Patient 2's husband called to inform her that Patient 2 had received a written prescription for Percocet (pain medication), which belonged to Patient 1. RN 1 further stated that Patient 2's physician was made aware and met Patient 2's husband at the hospital and provided the correct written prescription for Tylenol 3, at that time. RN 1 further stated during the same interview, that the discharge process included: The RN reviews the Discharge Summary to verify medications and follow up instructions, checks the medical record for written prescriptions and transcribes the information onto the Depart Summary. The Depart Summary is read to the patient and then, both the patient and RN sign the Depart Summary. An interview was conducted with the WSNM and RN 2 on 11/27/13 at 9:30 A.M. RN 2 stated that she was not aware that Patient 2 did not receive the correct prescription until after Patient 2's husband had brought it to the hospital's attention. In addition, RN 2 stated that the discharge process included: The RN reviews the Discharge Summary to verify medications and follow up instructions, checks the medical record for written prescriptions and transcribes the information onto the Depart Summary. The Depart Summary is read to the patient and then, both the patient and RN sign the Depart Summary. RN 2 stated that she overlooked the name on the prescription written when she gave it to Patient 2. RN 2 acknowledged that it was the responsibility of the discharging RN to review the Depart Summary with the patient to ensure that follow up instructions and medications which were prescribed to the patient, were accurate. Then, both the patient and RN signed the Depart Summary. The hospital's policy titled "Discharge Summary" revised 07/2011 indicated that patient identification was to be included on all discharge instructions including medications; dated timed and authenticated by the person responsible for providing the service. The hospital's policy titled "Health Information: minimum Necessary Access, Use & Disclosure" revised 07/2011 indicated reasonable measures must be taken to limit the disclosure of protected health information. RN 1 and the WSNM acknowledged that Patient 1's PHI was not protected when Patient 2 received a written prescription which was not verified by patient identification and intended for Patient 1.
Outcome:
Deficiency cited by the California Department of Public Health: Patients' Rights