CT Center for Patient Safety Newsletter
March 2011








We want to support quality care and access for all CT residents - this legislative initiative could be the way to do it.  Except for one omission and Section 13.

The bill mentions safety only once - and patient safety not at all.  More than  fifty Connecticut professionals worked together on a subcommittee addressing quality and patient safety for over a year.   In the drafting of the bill, our work was largely overlooked and there was no recommendation made to see that once the bill was passed our committee, in some form, might reconvene.


Section 13 provides a Safe Harbor for doctors who participate in SustiNet.  Four of us testified - our own stories about negligence but also the dangers of creating a two-tiered system of justice: one for individuals in SustiNet and another for those in other health plans.  Further, section 13 takes away our constitutionally guaranteed  acess to our court system.  Senator Andrea Stillman assured us that the wording and limitations would be addressed.  But always it is behind closed doors and with special interests represented.  What is wrong with including us - the health care consumers-in those meetings?  We still have to pound those doors to be included.


More errors result of physicians not listening: study

 By Joe Carlson

Posted: February 24, 2011 - 12:01 am ET

Tags: Patient Safety, Physicians


Great effort goes into stopping preventable errors such as wrong-site surgeries, but authors of a study on unwanted variation in elective procedures say that many more errors are taking place because physicians are not listening to their patients.

The latest report from the Dartmouth Atlas Project -Improving Patient Decision-Making in Health Care, which was conducted in conjunction with the Foundation for Informed Medical Decision Making -concludes that if physicians educated and listened to their patients more thoroughly, unwanted variation would decline.

Researchers took an in-depth look at medical conditions involving decisions for elective care in cases where the statistics don't recommend a single course of action. For example, the report found two- and three-fold variations in incidence of surgeries for lower back pain, and in prevalence of lumpectomies plus radiation for treatment of early-stage breast cancer.

The study found that much of the difference is attributable to physicians' preferences, not differences in patient populations. But in cases of elective procedures, giving a patient a treatment he doesn't want is as much an error as wrong-site surgery, said Michael Barry, a co-author and president of the decision-making foundation.

"The patient safety movement over the next decade needs to think about reducing the rates of those errors, which we think are made quite often as well," Barry said.

203 247 5757

Dear Members.


HealthGrades has just released a new study confirming the grim statistics of growing documentation of preventable deaths.  HealthGrades is a leading independent ratings organization and over an eleven-year period, and more than 140 million Medicare patient recordsm has estimated that there have been over 500,000 preventable deaths of Medicare patients in the last decade.  Just think if they had added in all patients into this analysis.


Rosemary Gibson, a long-time friend of our organization and author of two important books, White Wall of Silence and

The Treatment Trap, believes that the latest statistics underestimate the scope of the problem.



"I calculate 250,000 preventable deaths a year from health care harm, which
is 10% of all deaths in the U.S. annually.
The basis for the estimate (all rough): 100,000 from medical mistakes; 100,000 from infections; 19,000 from unnecessary surgery, 15,000 from radiation from CT scans, and the remainder from medication interactions that are not from mistakes as defined by the IOM but from chaotic prescribing."

We need to increase the volume.  Please share these statistics with local media, your legislators and your friends.  We know the individuals and their families that these grim statistics represent. 
When is enough enough?



 The patient's voice in policymaking

By Brenda Shipley, CTCPS Board Member


This week I did something for the first time. I went to the Capitol to testify against passage of a bill that gives medical providers safe harbor in the event they injure their patients.


I sat at a microphone in front of state legislators and told them my story. I condensed seven years of pain and suffering from medical malpractice into a handful of sentences, in the hopes that long after the public hearing and my three-minute testimony ended, these legislators will recall my face and my voice, as they deliberate the bill's language.


Our patient stories personify dry statistics and policy language. We bring issues to life, making them memorable, when we speak up and speak out. In order to affect pro-patient safety policy change, we must each find the courage to step into the bright spotlight of the ring, into our circus of democracy, and with our own words bellow, "Ladies and Gentlemen"...





written by John Torello

May 2006, my wife gave birth to two beautiful twin boys. They were 7 weeks premature, but relatively healthy with Apgar scores of 9.  Michael weighed 5 lbs, 5 oz., Matthew weighed 4 lbs, 7oz. They were admitted to the neonatal unit for respiratory concerns, which are common in preemies. Matthew was smaller and initially in slightly worse shape than Michael. Over the next week Michael's condition worsened, and he suffered a pulmonary hemorrhage. While the doctor's were focused on his respiratory condition, they neglected to attend to the big picture. Michael's bilirubin level increased (he was jaundiced). We questioned why he was not being treated with phototherapy, as many of the babies in the unit were. We were told that they didn't feel it was necessary to treat at the time. In July 2006 he had an MRI that we were told was inconclusive. For the next 10 months Michael was in and out of the hospital;  he was diagnosed as profoundly deaf and had very poor tone and no fine or gross motor control. In March of 2007, he had a second MRI. This time the results were clear:  he had Kernicterus. This is a severe brain injury that causes deafness and severe cerebral palsy. It is the result of untreated jaundice.

Today Michael is 4 years old. He can hear, but we don't know how well, as testing is very difficult. He still has poor tone and motor control. This affects his ability to eat, communicate, and breathe properly. He cannot walk, sit up, or hold his head up. His condition exacerbates his respiratory issues and severe acid reflux. The bilirubin that damaged his brain also did severe damage to his teeth. He had 6 teeth removed and 8 root canals by the age of two.

Today he requires daily respiratory treatment, weekly occupational therapy, physical therapy,  speech and language therapy, oral motor therapy, thera-suit therapy, craniosacral therapy and special education services. He regularly needs to be seen by a pulmonologist, an orthopedist, an ophthalmologist, a neurologist, a gastroenterologist, a dentist and a pediatrician. He has a feeding tube directly into his stomach, and has been hospitalized several times since his birth. By comparison, Matthew has slight asthma and requires an occasional asthma pump. In order to care for our son , his mother can never return to her work as a teacher. Fortunately, he is very smart and very strong willed. He shows gradual improvement. He enjoys his 3 siblings, swimming and preschool.