Issue: Patient A contacted Pharmacy Call Center reporting that he had a bottle of medication belonging to Patient B. Both patients had prescriptions for the same medication and strength filled here in Lebanon on 12/22/10 at separate times. Supervisor cannot be…

Outcome: Staff educated and new perscription mailed to patient.

Issue: Records released to a family member without proper authorization Update: 01/20/11:Veteran will receive a letter offering credit protection services.…

Outcome: LETTER SENT OUT NOTIFYING VETERAN OF VIOLATION AND OFFERING CREDIT PROTECTION

Issue: Patient A changed his address and did not notify VA before Rx was sent from the Charleston Consolidated Mail Outpatient Pharmacy (CMOP). Patient A's name and type of medication was compromised. Charleston CMOP investigation concludes that this is the result…

Outcome: Charleston CMOP investigation concludes that this is the result of a VAMC incorrect address transmission leading to a USPS misdelivery, not a CMOP packaging error. The medical center has been notified.…

Issue: Patient A received a prescription intended for Patient B. Patient Bs name and type of medication was compromised. Patient A reported the incident to the medical center and a replacement has been issued for Patient B. Tucson Consolidated Mail Outpatient…

Outcome: The process for packing prescriptions at multiple stations is under review and will be revised in an effort to prevent future errors of this nature.

Issue: Outpatient Pharmacy Service was notified that a Veteran did not receive his medication sent via UPS (United Parcel Service). The Privacy Officer was informed by Outpatient Pharmacy Service that there has been a loss of a patient\xe2\x80\x99s methadone in the…

Outcome: The DOB is no longer on either the batch label or the RX label as a Date of Birth. It is now "masked" as 679-month-day. It would show up 6790102. This will be on BOTH the RX label and removed…

Issue: While seeing patients in clinic on 1/20/11, a patient told pharmacist that stapled to the back of his medication reconciliation handout was a letter to a different patient regarding an upcoming appointment. The patient received the handout upon checking in…

Outcome: Since this type of error has occurred multiple times, the facility director has informed the supervisory staff and the Human Resources staff that each offense will result in an automatic reprimand. A letter to all employees was sent to inform…

Issue: Mailing label for medication packet of Veteran A fell off the box and into the medication bucket for Veteran B. Medication packets mailed to Veteran A. Update: 01/21/11:Veteran A will receive a letter of notification since his medication information, name…

Outcome: Education to Pharmacy on need to double check mailing label to med going out in mail.

Issue: There has been a loss of a patients medication in the United Parcel System (UPS). The medication was filled normally and sent out on 1/13/2011. The veteran contacted the pharmacy and verified that he had not received the medication as…

Outcome: The DOB is no longer on either the batch label or the RX label as a Date of Birth. It is now "masked" as 679-month-day. It would show up 6790102. This will be on BOTH the RX label and removed…

Issue: During home visit by VA Employee, Veteran/patient handed VA Employee a copy of medication profile which belonged to another Veteran/patient. When VA Employee tried to retrieve it back from the Veteran/patient they were evaluating, the Veteran/patient grabbed the copy of…

Outcome: Veteran/patient has refused to give medication profile to VA employee during home based primary care visit and Veteran/patient has refused to answer any questions on how this information was obtained.

Issue: An employee's six-part (personnel) folder is missing, as well as his service card, which contains all identifiable information and employment information. Update: 01/22/11:Employee will receive a letter offering credit protection services since his full SSN and DOB are on these…

Outcome: LETTER SENT TO EMPLOYEE OUTLINING INCIDENT AND OFFERING CREDIT MOITORING. OFFICES WHERE THE INFORMATION WAS STORED HAVE BEEN NOTIFIED IN AN ATTEMPT TO LOCATE THE FILE.…