CT Center for Patient Safety Newsletter
Investigative journalist making a difference November 15, 2009
In This Issue
Wrong sperm!
Hidden Mistakes
Doctor uses wrong man's sperm to produce twins.
The headline itself is shocking but even more shocking is the failure of the Department of Public Health to do more than slap this doctor on the writst.
For the full article go to 

 Debra Friedman who wrote this article is young and clearly talented. 
And another article hit the paper this week.
St Francis Hospital in Hartford is on Probation for one year. 
Another impressive journalist Arielle Levin Becker explores the failures of the hospital.  The problems varied but are serious.  They include reusing faulty device, inadeueate preventive maintenance of medical equipment, and surgical equipment stored in a soiled utility and biohazard trash room.
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Dear Members
This week, two explosive articles have been published and the investigative journalists who researched and wrote these articles have contriubted to our efforts of advocating reforms to improve patient safety.
And another article provides the back story to St Francis Hospital being placed on probabtion.

And don't forget to check out our blog http://patientsafetyct.org/
Hidden Mistakes
Hidden Mistakes In Hospitals
A state law intended to protect patients by making them aware of hospitals' errors has ended up making it easier for hospitals to avoid scrutiny.
The Hartford Courant
November 15, 2009
After a few weeks of nagging shoulder pain, Jonathan Faile of Fairfield drove with his wife to Bridgeport Hospital and walked into the emergency room early on the morning of Saturday, March 22, 2005.

An enzyme test indicated possible heart damage, so Faile's doctor prepared for a cardiac catheterization, a diagnostic procedure in which a thin tube is fed though an artery and advanced into the chambers of the heart.

One night in the hospital, the doctor assured, and then back to work on Monday.

But within hours, Faile was screaming in pain as blood gushed into his abdomen after surgeons accidentally cut his femoral artery. Soon afterward, with Faile's organs damaged by the excess pressure, doctors were bracing a stunned Justine Faile for the possibility that her husband might not survive the night.

He did. But over the next two months, Faile endured more than 20 surgeries, including the removal of virtually all of his large and small intestines, before Justine accepted that her husband could not be saved.

Jonathan Faile was 58 years old.

Under the state's "adverse event" reporting law, hospitals are required to inform the state Department of Public Health when patients suffer certain serious unintended harm. The legislation was intended to compel hospitals to improve care and help patients assess the quality of the state's medical facilities.

But since that law was revised five years ago, the mishap at Bridgeport Hospital, and thousands of other incidents that injured or killed patients, have been hidden from the public by hospitals and the state health department. From minor accidents to deadly errors, public access to hospitals' adverse events has fallen 90 percent since the legislature redrafted the law.

Hospitals now report a fraction of the mishaps they once revealed; Bridgeport Hospital, for example, concluded that Faile's case did not meet the criteria for reporting, although a spokesman said the hospital conducted its own internal review.

But even when hospitals notify the state, the health department keeps most of those reports secret.

The details of more than a dozen sexual assaults are concealed in the health department's files, along with at least 30 cases in which sponges or other objects were left in patients' bodies after surgery, a Courant analysis has found. Information on hundreds of serious falls is also kept under wraps by the department, as are the particulars of at least half a dozen cases in which newborns died or were seriously injured during childbirth.
Fpr the rest of this amazing article. got to the courant.com.