CT Center for Patient Safety Newsletter
Quality Healthcare is a Right February 9, 2009
In This Issue
Public access to pharmacy prescription errors
Demand for reform grows

This year is like no other year. The state has no money yet demands for fundamental and radical reform to a dysfunctional health care delivery systrem are increasing. 
There is widespread agreement among providers, CT residents, policymakers, business and labor that the healthcare system as we know it is unsustainable.  It's hard to believe that despite spending twice as much per person as the other industrialized countries, Americans live an average of 1 years less in good health.
The core problem with American medicine is that healthcare itself has been turned into a commodity, and profits are optimized rather than the health of the patient.  We do not have a healthcare system but rather a collection of industries that make up an often dysfunctional system.  The consumer must negotiate and navigate all parts of this system and most often do that navigation without a map.
The CT Center for Patient Safety's mission is to work in our communities, within our healthcare systems and with elected officials to improve the quality of healthcare and to protect the rights of patients through education, accountability and advocacy.  We are all about systems change - changing the system so that the patient is the point and purpose of care and not a cog in the payment stream.
Our state of Connecticut needs to rebuild healthcare delivery by:
         Establishing patient centered medical homes
         Paying for quality and evidence based care
         Widespread use of portable electronic medical records
What role can the CT Center for Patient Safety play in helping to assure that patients become the focus of healthcare?  Persistent and consistent advocacy about the needs of the patient will be critical to assure that reform meets consumer need.

PO Box231335
Hartford CT 06123
203 247 5757
Be it enacted by the Senate and House of Representatives in General Assembly convened:
That the general statutes be amended to require the Department of Consumer Protection to make available to the public information about performance errors committed by pharmacies and pharmacists in the dispensing of prescription medications.
Statement of Purpose:
To provide the public with information about errors committed by pharmacies and pharmacists.
And one of our members submitted powerful testimony.
"I am speaking to you as the mother of a baby who was the victim of not one but two (2) pharmacy errors. These errors occurred at the same time at the same national chain pharmacy. In one error a medication intended for use in her ear was mislabeled with instructions that it be placed in her eye. In the second she was given a completely wrong medication. I have since come to find out that the State of Connecticut offers very little protection to consumers in the arena of pharmacy errors.
I contacted the Department of Consumer Protection's Drug Control Division and followed through with everything I was asked to do. I spoke with an agent both on the phone and in person. I turned over the prescription bottles to help with their investigation. I made myself available in case I would be needed for any hearings. Then I discovered that citizens of the state of Connecticut are not entitled to ANY information concerning pharmacy errors.
Even as the victim of these errors we were not entitled to ANY information about how they could have occurred or what has been done to ensure that they do not happen again. All investigations are considered confidential. We could not ascertain if this pharmacy or this pharmacist has a history of these types of errors. We could not even find out if this case led to any sort of sanctions, retraining or investigation. At one point when trying to retrieve our bottles of medication we were even told that there was no history of our ever having filed a complaint. Clearly this must change.
Each month I read the minutes of the Pharmacy Commission meetings to see if I could find any information on what, if any action may have been taken. Surely, I thought, with two such egregious errors something had to be done. I discovered that all pharmacy errors are recorded only by case number, which is also kept confidential. No identifying information concerning the pharmacist, the pharmacy or even the town where the error occurred is listed. As long as the pharmacist completes a continuing education course on prescription errors the case is dismissed. A pharmacist who commits 2 errors in a three year period may have their name published if they are the subject of a hearing. Apparently 2 errors occurring on the same evening did not merit a hearing, though. Our pharmacist and pharmacy were mentioned only one time in the minutes - when the Pharmacy Commission approved her promotion to pharmacy manager 5 months after these errors occurred.
I have come to ask that you allow consumers access to error histories for pharmacies and pharmacists so we have the opportunity to make informed decisions about an important part of our health care. There were 5 other pharmacies located within 2 blocks where I could have filled these prescriptions. We can make such informed decisions concerning doctors and hospitals so why not pharmacists?
An agent with Drug Control told me that the only way to learn about errors is to hope that victims go public. Also, since many errors are committed by pharmacists who have developed substance abuse issues they protect them in hopes that they will seek treatment. While I am all for people seeking help with substance abuse issues I believe that it is more important to protect the innocent consumer.
I do not want my daughter to be the next victim of someone with a history of errors. She has already been victimized enough."

AHRQ Director Helps Consumers Navigate the Health Care System in a Web Advice Column
AHRQ Director Carolyn M. Clancy, M.D., offers advice to consumers in new, brief, easy-to-understand columns.  The biweekly columns will help consumers better navigate the health care system.  Select to read Dr. Clancy's advice columns. 

This website is a rich source of information for the consumer.  It goes far beyond the advice column and deals with many quality issues that are important to the consumer
November 2009 will mark the tenth anniversary of the IOM report - To Err is Human
CTCPS is beginning to plan a day of recogntion of the adverse events behind those statistics.  in other words -our collective experience and our stories.  Please contact Jean Rexford at 203 247 5757 with your ideas.