CT Center for Patient Safety Newsletter
November 2, 2009 
In This Issue
Money Driven Medicine
Understanding the ethical issues behind negligence
How clean is that hand you are shaking?

Money Driven Medicine
Free online viewing, and details for arranging airings, can be found on the website moneydrivenmedicine.org.  
Film explores broken health care system
A new documentary film, "Money-Driven Medicine", tackles the economic underpinnings of an American healthcare system that kills four times as many people through medical error and preventable infections as die in highway accidents.
 The 86-minute film explores a vexing question now on the minds of many Americans:
How can a country that spends $2.2 trillion a year on health care - more per capita than anywhere - wind up with higher infant mortality rates and poorer hospital-care outcomes than other wealthy countries?
"The United States doesn't really have better care than other Western Democracies," explains Dr. Donald Berwick, President and CEO of the Institute for Healthcare Improvement. "It just has more care."
The film is a collaboration of a non-fiction book author, Maggie Mahar, and documentary filmmakers led by Alex Gibney ("Taxi to the Dark Side" and "Enron: The Smartest Guys in the Room").
It traces the explosive build-up of America's medical-industrial complex since the advent of Medicare. It proposes that the system isn't patient driven, as a social program like Medicare might have envisioned, but instead stockholder driven, and technology crazed.
As Berwick notes in the film, the system is capable of providing "audacious" cures for complex deadly conditions, but fails to offer optimum everyday community-based care for the average patient's chronic conditions.
California Newsreel, a San Francisco-based distributor of social issues films, is working with organizations like Consumers Union to urge Americans to conduct living-room "Watch Ins" of the film as congress debates healthcare reform. Consumers Union reports 175 home viewings have been arranged, along with larger community airings scheduled or planned in Seattle, Washington D.C., Houston and Austin.

Save the date! Consumers Union Safe Patient Project live forum webcast -- November 17, 2010
Consumers Union's Safe Patient Project (formerly Stop Hospital Infections) is holding a forum, "To Err Is Human, To Delay Is Deadly," in Washington DC on November 17th.  You are invited to view the free live webcast on the day of the event. The forum marks the 10th anniversary of the IOM study on medical errors and raises concerns about the lack of progress over the past decade in preventing medical harm. The Safe Patient Project campaign released a report earlier this year on the subject. The campaign covers the following issues: hospital-acquired infections, medical errors and other medical harm, physician accountability and drug safety.
For more information on the forum speakers, presentations and webcast click here: http://cu.convio.net/site/PageServer?pagename=spp_webcast_page The webcast will be available on the day of the event. Please RSVP if you'd like to view the webcast and Consumers Union will send you a reminder before the event. 
Dear Members,
Another trip to DC - we continue to try to remind our Congressional delegation that malpractice is about negligence and preventable error. Herman Cole, Bill Tyra and Mike Moran traveled to our nation's capitol. Mike came home and wrote his sermon for the the following Sunday and I have included it in our newsletter. He points out "my car in the hospital parking lot had greater protection under the law than any of us did as patients inside - at least if someone did significant damage to your car and failed to report it they would be subject to arrest, but you could be permanently disabled in the hospital and the wall of denial and silence would go unpunished."
Thank you Bill, Herman and Mike.  
203 247 5757 

Senior Pastor
Rev. Michael J. Moran 
First Congregational Church, New Milford 

When I typed in this week's sermon title my spell checker kept telling me that felicitude was not a word.  Felicity was easily recognized as meaning happiness, but I thought faith and felicity sounded a bit too close to an eharmony.com double date, so I stuck with felicitude - it rhymes with gratitude.   I didn't have much time since I was going to be out of town Tuesday, Wednesday, and Thursday, so the sermon title decision had to be made first thing Monday.
The reason I was out of town had very little to do with faith or felicitude.  Some of you know that in 2004 my mother in law was permanently disabled by a medication overdose in the hospital.  The medical error was compounded by the fact that we went ten weeks making life and death decisions without knowing that her condition was caused by medical error.  Even when we were told about the overdose, it took three more years and forcing people to testify under oath before we really understood what went wrong.  It surprised me to learn that in Connecticut a medical error has to be reported to the state, but there is no law that the patient or the family of the patient has to be told.  I was put in touch with the Connecticut Center for Patient Safety who works on these kinds of issues at the state level, and through that contact got asked to travel to Washington last week to speak with our Representatives and Senators about making patient safety a priority in health care reform. 
There were groups from all over the country, and each group went to meet their own Congressional delegation.  We met with Murphy and Himes and staff for DeLauro and Lieberman, but the people I really got to know were the five other families from Connecticut who traveled to DC to tell their stories.  The stories ranged from terrible to tragic - we were a parade of sadness.  I spent the most time with a retired United States Marine Colonel whose daughter had died after a medication error which then was covered up by attempts to alter hospital records.  His case involved criminal indictments and  prosecution.  My repeated point was that my car in the hospital parking lot had greater protection under the law than any of us did as patients inside - at least if someone did significant damage to your car and failed to report it they would be subject to arrest, but you could be permanently disabled in the hospital and the wall of denial and silence would go unpunished.
Some of the people in our small group from Connecticut had been to hell and back, but I tell you they had a resilience about them, a determination to press forward that was most remarkable.   Not all the time we spent together was dark and grim, there was sympathy, empathy, community, and even moments of felicity as we worked our way from building to building, from elevators to tunnels, from security checkpoints that sounded loud alarms at some of the prosthetic hardware, from small cramped offices to the spacious Rayburn room just off the chamber of the House where congressmen scurried in and out between votes.   It was not the pomp and privilege of power that most impressed me that day, it was the fortitude and faith of my companions that I will never forget.
Ever wondered if the hand you are holding or shaking is clean?
The New York Times reported that simple reminders seem to increase the odds that people will wash their hands with soap and water.  Absent such reminders the study found, only 65 percent of women and a pathetic 31 percent of men used soap.  But different messages resonate with men and women.  Women will wash their hands when they see a simple sign :Wash your Hands with Soap" but men needed a more graphic message.  The most effective sign in the men's room was "Soap it off or eat it later."
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