VA Eastern Kansas Health Care System - Dwight D. Eisenhower VA Medical Center

Issue: A Pharmacy student was seeing a patient in Chronic Disease Management (CDM) clinic. When the student came to check out with supervisor with regards to the patient and possible medication changes, the student had the days patient list (which contained…

Outcome: 06/22/15: The Incident Resolution Service Team has determined that four Veterans will be sent a letter offering credit protection services.…

Issue: The Privacy Officer (PO) received a call from Pharmacy who reported a Veteran returned a medication of a fellow Veteran with a very similar name. This medication had been overnighted to him. The medication was returned the following day without…

Outcome: 01/22/15: 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: Veteran A returned a report to the nurse at the Community-Based Outpatient Clinic (CBOC) once he noticed it wasn't his. Veteran A had just returned home from the Medical Center where he is not sure how he came about obtaining…

Outcome: 01/16/15: The Incident Resolution Service Team has determined that the 42 Veterans will be sent a letter offering credit protection services.…

Issue: Veteran A received approximately 11 pages of Veteran B's medical information via a mis-mailing by the Release of Information (ROI) Office. Upon noticing the information wasn't his, Veteran A promptly returned the information to the ROI Office who reported it…

Outcome: 12/01/14: 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: During a Vista sensitivity log review (on Oct 3rd), the ISO detected that an employee accessed a chart in CPRS of a patient that had the employees same last name. ISO verified with the supervisor to determine whether the employee…

Outcome: 10/06/14: The Incident Resolution Service Team has determined that Patient A will be sent a HIPAA notification letter due to Protected Health Information (PHI) being disclosed.…

Issue: This was initially reported as a MyHealtheVet glitch issue which turned out not to be the case. A progress note was inadvertently entered in the wrong Veteran's record; who in turn accessed their information through MyHealtheVet record and reported seeing…

Outcome: 09/29/14: The Incident Resolution Service Team has determined that Veteran A will be sent a letter offering credit protection services.…

Issue: It was reported by Life Insurance Company [upon 2nd request for medical records] that the Release of Information (ROI] Department disclosed the medical records of an individuals father in lieu of the son (the authorizing individual.) However, the name appearing…

Outcome: 09/29/14: The Incident Resolution Service Team determined that there was an erroneous disclosure however there is a low risk of compromise. It was verified on 09/23/14 that the insurance company had shredded all information received from this facility.…

Issue: Clinician reported that upon referral for nursing home placement for Veteran, a couple documents were mistakenly faxed to another business. The business notified us stating first page was the our fax cover sheet. The second page sounds like the first…

Outcome: 09/03/14: The Incident Resolution Service Team has determined that the Veteran will be sent a letter offering credit protection services.…

Issue: It was reported by a Veteran (Veteran A)that he received a fellow-Veterans (Veteran B) CD mistakenly. The Veteran doesnt have a computer so couldn't/didn't view but had requested this image for an outside provider appointment. However, the SORNA Machine prints…

Outcome: 07/25/14: The Incident Resolution Service Team has determined that Veteran B will be sent a letter offering credit protection services.…

Issue: It was reported to the pharmacy by Veteran A that he did not receive his Fentanyl medication. After further investigation, it was discovered the prescription was delivered to Veteran B, in error. Both of these Veterans are prescribed Fentanyl medication/same…

Outcome: 06/25/14: The Incident Resolution Service Team determined that Veteran A will receive a HIPAA letter of notification.…