The medical test results of at least 14 military veterans were erroneously mailed to other patients of the VA Northern Indiana Health Care System, according to a report on the matter by the U.S. Department of Veterans Affairs.
Jay Miller, acting director of the system, said Monday that an eight-person committee has been formed by the system to consider "avenues of improvement" in mailing procedures.
"We’ll review the whole program and process to eliminate possibilities of mail-out errors," Miller said in a telephone interview.
Deana Bonner, privacy and Freedom of Information Act officer for the VA Medical Center in Saginaw, Michigan, reviewed the mistaken mailings but said in her findings that she "was unable to determine if the error was a result of an employee handling or a malfunction of the equipment."
Bonner recommended that the Northern Indiana system implement a process to ensure that mailing machinery functions properly and evaluate the types of letters that are run through the machinery.
Miller said all the letters that missed the intended patients – "at least 14 that we’re aware of" – apparently were processed June 22 at a VA mailing hub in Marion. The committee tasked with reviewing and perhaps improving mail procedures was informed that a letter-folding machine might have malfunctioned, the machine operator might have selected the wrong number of pages to be folded or staff might have sorted letters incorrectly.
WANE-TV reported July 12 that a Fort Wayne veteran had received medical test results meant for two other veterans who are patients of the Northern Indiana system, which has medical centers in Fort Wayne and Marion and clinics in Goshen, South Bend, Peru and Muncie.
On July 18, Sen. Joe Donnelly, D-Ind., called on Miller to investigate and produce a "long-term solution to ensure this never happens again."
Bonner reported to Miller on July 25: "Envelopes containing test result letters to multiple patients were mailed and received by more than one patient. Fourteen patients were identified that their test result letter was mailed to a different patient."
Those 14 patients were notified by telephone of the errors, Bonner wrote.
She said the letters were prepared for mailing by a machine that folds and inserts each letter into an envelope, seals the envelope and stamps postage on it.
Miller said Bonner’s report had been sent to Donnelly, whose office confirmed receiving it.
"I look forward to hearing from Director Miller about the VA Northern Indiana Health Care System’s plan to implement the necessary policy changes to protect the privacy of veterans," Donnelly said in an email.
Miller said VA officials could consider increasing the use of electronic communications with patients or contracting with a private mailing company. He said the Northern Indiana system already uses a private contractor for a portion of its mailings.
"We want to look at the whole program and take a real hard look in terms of specifically what we’re mailing out, where we’re mailing out. I think it’s important to review the whole process," Miller said.