CT Center for Patient Safety Newsletter
Update March 19, 2010 
In This Issue
1956 hospital expose
The Lilly Heist
New Adverse event study
Even in 1956 they were worried about patient safety.  Too bad so little has been done to assure quality care.  This was provided to us by Steve Govoni, Board member and Past President,  whose father worked at Confidential Magazine in the 50s.

This is an excellent website - full of solid information.  It is an independent review of current health stories.  Are you as confused as I am about the conflicting reports?

Quick Links
and Jean Rexford's phone number
203 247 5757
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PO Box 231335
Hartford CT 06123
Dear Member,
By the end of next week we will know a lot more - whether we have national health reform and whether or not our Public Health Committee has voted out two important pieces of legislation - our pharmaceutical gift restriction bill and our hospital specific adverse event reporting.  I will be keeping you fully informed because, as you know, your voices need to be heard.  Thank you so much for keeping me in the loop and letting me know when you have heard from your state representative and/or your state senator.  Hats off to our lobbyist, Bob Shea who is always there for us. He is a fine strategist and a very good friend to our organization.
If our legislation begins to move, you will be the first to know.

The astonishing theft of $75 million worth of antidepressants and other drugs through the roof of an Eli Lilly distribution warehouse in Connecticut earlier this week is just the latest and most acrobatic incident in a rash of prescription drug theft, and highlights the importance of establishing better tracking of drugs in the pharmaceutical supply chain. According to Freightwatch, a group that tracks cargo security, drug theft has quadrupled in the last four years. Last year, nearly $200 million worth of prescription drugs were stolen in the U.S. There were five pharma thefts in the month of February alone.

The case highlights the need for a start-to-finish, tamper-proof drug pedigree on every prescription drug that's sold. As the Secure Pharma Supply Chain blog wrote, "the issue of pharmaceutical cargo theft energizes the need for material screening of products within the supply chain, from manufacturer to dispenser, to properly protect consumers everywhere."

Right now, prescription drugs that go missing (through the roof or otherwise) are often exempt from having a pedigree once they reach a hospital or pharmacy because of regulatory gaps. Under current federal and state regulations, many parties are excluded from pedigree requirements - authorized distributors,  for one - so a drug's paper trail ends once it passes through their hands. Stolen drugs, which may be improperly stored or tampered with, can be sold back to authorized distributors, and pharmacies and hospitals that buy from them have no way of knowing of the risks.

Another problem is that it's a paper trail-and those papers can be easily swapped,  forged or lost.  And the documents that are required are for whole lots of drugs, making them meaningless in issues of partial-lot theft.  We have seen resale occur (like the insulin units stolen from North Carolina cargo truck and found on Texas shelves months later.) One solution would be to require an e-pedigree, an electronic barcode or radio tag on every bottle or package of prescription drugs, making it possible to track each stop along the supply chain from the factory to the medicine cabinet. 

New Adverse Events Study is more than troubling
1. Patient diagnosis codes were inaccurate or absent for seven of the eleven Medicare hospital acquired conditions.  This problem would prevent Medicare from identifying the problems and it would also lead to overpayment.  (Isn"t this fraud?)
2. Reviewed hospitals did not generate incident reports for 93 percent of the events, including some that involved death and disability.  The lack of reporting could prevent hospitals from tracking events as required by Federal regulation and suggest that the information provided to the Patient Safety Organization is inadequate and unreliable.
This study was undertaken by the Office of the Inspector General.