CT Center for Patient Safety Newsletter
February 1, 2011



Connecticut media coverage of our issues has been more than impressive.

In this issue I have included some of the recent coverage that is drawing attention to our concerns as health care consumers.  We may have reached a tipping point - we have persistently tried to focus attention on what concerns us as health care consumers.  When I read these articles, I thought - great someone is listening.


The legislative session is underway - look for special bulletins.


Dr. Jewel Mullen is our new Commissioner of the Department of Public Health.  I had an opportunity to meet her and look forward to her background in public health to represent the needs of all residents in our state.

Medical errors take an horrendous toll

Posted by CTCPS on Jan 10, 2011

Public News Service-CT

January 10, 2011

CT Advocate: Medical Errors Take a Horrendous Toll

REDDING, Conn. - Every year, 180,000 Americans die because of medical errors, according to a new report from the U.S. Department of Health and Human Services. It also says the number of deaths has been steadily increasing for the past ten years.

Jean Rexford, executive director of the Connecticut Center for Patient Safety, says an earlier report showing 100,000 deaths annually was treated with skepticism by some in the health care industry, but now, more proof is available.

"This report, that came out in December, substantiates not only that those numbers were valid, but that the scope of the problem is far greater than anyone ever thought."

The numbers of deaths are equivalent to a jet full of passengers crashing every day, but the fatalities are scattered around the country and don't often make the news.

Rexford says as the population ages, more people go to the hospital for various kinds of treatment, where they're likely to run into problems.

"An estimated 134,000 Medicare beneficiaries were experiencing at least one adverse event in hospitals during a one-month period."

Many of the errors do not result in death, but Rexford says they mean greatly increased medical costs for the nation's taxpayers. The estimated total is more than $4 billion a year in additional Medicare payments.

"Every single thing that happens that shouldn't, generates costs that are unnecessary."

To address the problem, health care watchdog groups say multiple doctors treating the same patient need to understand the whole picture, and using checklists in hospitals can also help to reduce medical errors.

Join Our Mailing List

Recently Ina Blair died.  Her son thoughtfully named the CT Center for Patient Safety as the organization designated to receive gifts in her memory.  Jerry we are sorry for your loss but appreciate your generosity. Barbara Tyra and Lisa Freeman also named our organization when their beloved husbands died.

We will do our best to continue to represent patient voices and do honor to your hopes for a safer system of care. 


Dear Members,


It looks as if tort reform will be a national priority - despite the fact that it makes no sense.  Obama has said that tort reform and patient safety must be new priorities.  We can all agree on patient safety but we know firsthand, that when most trade associations, the American Medical Association, the hospital associations, for example, talk about medical malpractice reform, that it translates into little accountability and transparency, the very qualities that can push reform of systems of care.  Just compensation for injury might mean one thing to the doctor or the hospital, but to the family of a severely disabled child, the hospital's concept of just compensation would inadequately meet need.


Another issue -  doctors say they must practice defensively due to medical malpractice and frivilous lawsuits.  First, in the nine years I have been working with victims of negligence, I have never met a frivilous lawsuit.  Far more likely, I believe is that a lot of overtesting has more to do with conflicts of interest  as doctors may own the technology that must be paid for or have a financial interest in the testing facility. 


Medical errors take an enormous toll not just in human suffering but in costs to our healthcare system.  Let's address the preventable errors before we tamper with the Constitution and a citizen's access to our court system.




Harm in Hospitals

Preventable deaths They will continue until there is a national strategy to stop them

January 10, 2011


Two recent reports exposed the disgraceful fact that Americans are at risk of dying from preventable medical errors and lapses in treatment when they go to hospitals to get help. It's time that Congress addressed this issue on a national level, instead of letting each state decide to do something - or not.

A report in the New England Journal of Medicine showed that hospitals are not getting safer for patients. A study of 10 North Carolina hospitals found that harm, much of it preventable, was quite common. Medication errors, complications from procedures and hospital-acquired infections led the shameful list.

This study found that 18 percent of patients were harmed by medical care. Some were harmed more than once. More than 60 percent of injuries were thought to be preventable.

A study on the Medicare population by the office of the inspector general of Health and Human Services, said that harm - again, largely due to preventable errors - contributed to prolonging treatment or hospitalizations of 134,000 Medicare patients in one month (about one in seven patients). Medical harm contributed to the deaths of as many as 15,000 in one month. This study showed that nearly half of all the preventable problems occurred because of medication errors.

These two studies show that there has been little to no progress since the landmark 1999 report, "To Err is Human," showing that between 44,000 and 98,000 are killed in hospitals due to preventable medical errors.

This situation is intolerable.

Medical officials frequently laud the voluntary steps that hospitals and medical personnel are taking to improve patient care, and there's no question that people want to do better and mean well. But the voluntary efforts have made the nation a patchwork quilt. A little more than half of all states and the District of Columbia (including Connecticut) track medical errors and medical harm done in hospitals. But half the states don't even do that much. How can they know what's going on if they don't keep track of problems?

The nation needs one national repository to keep track of medical harm, adverse events and problems that occur to hospitalized patients. Only then will there be an organized approach to addressing these errors - and a systematic determination to prevent unnecessary and preventable deaths in hospitals, improving patient care for everyone.

/Negligent Physicians Connecticut Medical Examining Board needs to toughen up

December 24, 2010

What do you do if you're a physician in Massachusetts, Rhode Island or New York and have been disciplined by authorities - maybe even lost your license - for, say, taking drugs, having sex with your patient or delivering negligent care?

A number of doctors and other health care professionals sanctioned in those neighboring states for such offenses have set up practice in Connecticut. Why? Because authorities here are far more lax.

Connecticut too often overlooks disciplinary incidents that occur elsewhere or applies restrictions that aren't tough enough.

Some of the best medicine in the nation is practiced in Connecticut, but sadly there is a hard-to-change culture in the health care community here of trying to paper over mistakes.

Progress has been made in publicly reporting hospital errors.

But the Connecticut Medical Examining Board, a volunteer panel of mostly physicians appointed by the governor, has yet to put enough starch in its discipline of incompetent or negligent doctors. It's time to get as tough as our neighbors so that Connecticut is no longer known as a haven for bad practitioners.

Censured? Come To Connecticut

Journalists for the Web-based investigative team C-HIT recently conducted a study of licensing records of the past three years and found that more than a dozen physicians had escaped serious licensure actions in Connecticut although they had been issued reprimands or censures, and in some cases had their licenses revoked or were made to surrender them, in three neighboring states.

C-HIT found that some of the doctors who were sanctioned in other states promptly relocated to Connecticut, with no restrictions on their licenses. The medical examining board and the Department of Public Health, which investigates and brings complaints to the board for adjudication, presumably were aware of these discipline cases moving into Connecticut. They certainly have access to the information. Why didn't they act on it?

A study by the Public Citizen Health Research Group shows that Connecticut ranks an embarrassing 47th out of 50 states and the District of Columbia in the rate of serious disciplinary actions taken by state medical boards against physicians from 2007 to 2009.

History Of Troubles

This is nothing new. Connecticut has consistently been in the bottom 10 states in each of the last four three-year reporting cycles.

Connecticut's volunteer board is not the best model for protecting patients. The board and Public Health Department are often at odds, blaming each other when things go wrong.

In 2004, Deputy Health Commissioner Norma Gyle said the board of "doctors protecting doctors" should be abolished. Last year, Audrey Honig Geragosian, director of communications for State Medical Society, suggested the volunteer board be professionalized.

What About The Patients?

Connecticut's miserable record of cracking down on physicians who break the rules is a black mark against the state. Why isn't patient protection always an urgent priority? It can't be for lack of resources.

The Public Health Department will apparently propose legislation giving the state statutory authority to deem "as true" the findings of another state's disciplinary proceedings - rather than having to examine each out-of-state case as is done now. This will make it easier for Connecticut to impose the proper restrictions on physicians practicing here who got in trouble elsewhere.

That's a good, but belated start if the legislation comes to pass. Connecticut should meet or exceed what other states do in tracking and placing appropriate restrictions on physicians who get in trouble. This state needs to take every step necessary to shed the image of a disciplinary backwater.