CT Center for Patient Safety
November 2012
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An independent panel finds that Medtronic edited Studies


The New York Times reported that Medtronic edited studies by outside researchers about a controversial spine treatment.  Medtronic asserted that their device was superior to a competing device. The treatment is called Infuse and for the last several years, critics have charged that Medtronic had played down the risks.

The Spine Journal, last year, printed a report of spine specialists who repudiated the studies performed by the Medtronic financed research.

Where are criminal charges for this kind of duplicitous activity that can have such a devastating impact on patient's lives?
Medical Harm Complaint System Could be Quality Data Gold Mine 


Cheryl Clark, for HealthLeaders Media, October 18, 2012 - A first-of-its kind federal pilot project designed to make it easier for patients to directly complain about medical errors, safety issues, and harm may prompt some doctors and hospitals to blanch.   With the Office of Inspector General's estimate that one in four Medicare patients suffers harm at the hands of healthcare providers, could this new information really give providers any more information than by now, they must already know?


We may soon find out.  The pilot project proposed by the federal Agency for Healthcare Research and Quality (AHRQ) intends to give such a harm complaint system a trial run sometime next year, probably in the mid-Atlantic region near Philadelphia. Many say the information it will produce will be a gold mine for quality improvement.




Dear Members,
There are definite signs that there has been a shift in the way the medical establishment views patients.  On October 19th, I was asked to be on a panel - the National College of Surgeons Medical Liability Committee - discussing the impact of healthcare harm on patients.  Wherever I go I take you and your stories with me.  Putting a face on these egregious errors, asking my audience to show leadership in addressing the problems, gives me hope that at some point, we will have patient centered, patient safe medicine. 
I left for Washington discouraged.  I had just reviewed a draft of the annual hospital adverse event report.  The final version of the report will be accessible to you by early December.  It will be available to you because CT Center for Patient Safety worked on legislation that would require hospital specific public reporting.  There were 13 wrong site surgeries in our hospitals in 2011 and 3 wrong person surgeries.  There are no excuses for this!  What I would like to know is how these patients and their families were treated.  Were the errors acknowledged?  Was compensation provided?
We have talked a lot about improving the systems of provision of care.  And we, as patients, are counting on the implementation of simple systems to address repeated negligence.  At the College of Surgeons event, I learned that most problems are not system problems but still come down to the individual performance of our healthcare workforce.  We will persevere.



Lisa Freeman, Board Treasurer and I just attended a two day meeting in D.C.  PCORI stands for Patient Centered Outcomes Research Institute and brought together consumers, patients, caregivers, advocacy groups, researchers and other stakeholders from around the country in an effort to start building a patient-centered research community.  Getting patients more engaged in health care research, PCORI believes, is the key to producing information we can trust and use to make better - informed decisions.  PCORI hopes to support research that will include patients in helping to decide what should be researched, best methods to do the research and how best to disseminate the findings to the community.



The Economics of Health Care Quality and Medical Errors

Charles Andel, Stephen L. Davidow, Mark Hollander, and David A. Moreno

2012 article from the Journal of Health Care Finance



The authors concluded that 200,000 Americans die each year from preventable medical errors.  Direct medical costs added to disability claims and missed work means that the actual cost if nearly one TRILLION dollars.  The authors also concluded that providing quality care is less expensive!  Further, poor quality care is costing payers and society a great deal.


That seems like an understatement.  Because it is a financial journal, the article addresses the financial price we pay for negligent, substandard care.


Our stories address the human cost and the impact that the errors have on individuals and their families. 


What will it take to create change? 

And as always, thank you for your feedback and your support.


Jean Rexford
CT Center for Patient Safety
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