VA Central Iowa Health Care System

Issue: A supervisor stated that a couple of weeks ago, one of the nurses reported to him/her that she was dating a Veteran. She denied meeting him at work. Stated that she had known him in college. The supervisor went through…

Outcome: 05/29/15: The Incident Resolution Service Team has determined that the Veteran will be sent a notification letter, as the employee admitted to reviewing the patient record for medical test results without a business need.…

Issue: Veteran A's wife called to inform us that Veteran B's appointment memo was sent to her husband along with his own.

Outcome: 05/27/15: The Incident Resolution Service Team has determined that Veteran B will be sent a letter offering credit protection services.…

Issue: Veteran A was discharged from the hospital, and attached to his discharge paperwork was a Doctor's Order for Veteran B. Additionally, when he checked his medication, he received medication labeled for Veteran C.

Outcome: 05/21/15: The Incident Resolution Service Team has determined that Veteran C will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed and Veteran B will be sent a letter offering credit protection services.…

Issue: Veteran A called and stated that she received Veteran B's lab results along with her own in the mail. Veteran A forwarded the results to the correct recipient, Veteran B, before notifying the VA. The Nurse who took the call…

Outcome: 04/20/15: The Incident Resolution Service Team has determined that Veteran B will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: Patient A was given the lab reports of Patient B. This caused the Patient B to be given an incorrect diagnosis. The mistake was discovered by a Pharmacist and the Patient was contacted and the mistake corrected.

Outcome: 03/23/15: The Incident Resolution Service Team has determined that Patient B will be sent a letter offering credit protection services.…

Issue: A prescription form for Veteran B was mailed to Veteran A. Veteran A's wife called and reported the incident, and is sending the incorrect prescription form to the VA Privacy Officer.

Outcome: 03/05/15: The Incident Resolution Service Team has determined that Veteran B will be sent a letter offering credit protection services.…

Issue: Patient information referencing a change in medication and start of home IV Therapy was mis-faxed to a private citizen. The citizen called the VA and let us know. He stated he burned the documents.

Outcome: 02/05/15: The Incident Resolution Service Team has determined that Veteran A will be sent a letter offering credit protection services.…

Issue: A document was misplaced and never located.

Outcome: 01/22/15: The Incident Resolution Service Team has determined that Veteran A will be sent a letter offering credit protection services.…

Issue: Veteran received another Veteran's Non-VA Care Authorization form.

Outcome: 12/08/14: The Incident Resolution Service Team has determined that Veteran B will be sent a letter offering credit protection services.…

Issue: Patient received medical test results of three other patients along with his own.

Outcome: 12/08/14: The Incident Resolution Service Team has determined that three Veterans will be sent a notification letter.…