Result letters were processed in June at the VA mailing center in Marion, Ind. Jay Miller, acting director of the system, said the process of filing and mailing the letters is entirely mechanic: the letters are prepared by a machine that folds and inserts each letter into an envelope, seals it and stamps postage, according to the report.
An eight-person committee tasked to review the incident claims the error may have occurred due to a malfunction with the letter-folding machine or that the machine operator or staff may have sorted the letters incorrectly, according to the report.
Officials phoned the fourteen patients for whom the letters were intended to let them know of the incident.
The system includes hospitals in Fort Wayne and Marion, Ind.
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