CT Center for Patient Safety
CT Center for Patient Safety Newsletter
Janaury 2013
In This Issue
The Patients Changing Role
Transparancy and Accountability
Legislative Report on Adverse Events
Lapses in Medication Care



The Patients Changing Role


The word "patient" seems to be everywhere:  patient centered research, patient engagement, patient centered outcomes.  As I have said before, there is no road map for our patient safety movement.  We have learned to say "yes" when asked to participate. 


This year held many firsts for us.  The Institute for Healthcare Improvement held its annual conference and three patient representatives were asked to sit on a panel on "Engaging Patients: Let's Talk!"  I was privileged to be one of the three.


What an amazing discussion!  Yes, some professionals are engaging patients but we have a long way to go.  There are  states, such as Massachusetts, that require all hospitals to have family councils.  Other hospitals across the country are already doing this without being required.  It was encouraging to hear that the patient voice, when asked, has been instrumental in improving care delivery.  Common sense questions posed to the professionals in discussions such as this can help them understand what they need to do better to improve communication and the patient experience.


Ten years ago, none of this was happening.  In healthcare, change is glacially slow.  At CTCPS, we see ourselves in the forefront of this movement, providing expertise that will help speed up this process, both in Connecticut and across the country.

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 Dear Members,
Hospital Safety is a priority for everyone.  We would hope and expect that Connecticut hospitals would be amongthe best in the country, but they are not.  Instead, while there are islands of excellence, there is a sea of mediocrity.  We can do better.  Indeed, we must. Those working in our hospitals believe that they are doing a good job, yet report after report indicates we have a long way to go. Inertia in the land of steady habit is a big problem in our state.
We will continue to work together on hospital safety in 2013 making it a much happier New Year for Connecticut patients and their families.
Transparency and Accountability in Connecticut
The LeapFrog Group has dedicated itself to providing transparency and accountability on quality measurements.  Hospitals across the country showed great variation when it comes to patient safety.  Connecticut hospitals ranked 32nd in the nation.  Massachusetts ranked number 1, Vermont - number 5, Rhode Island - number 28 and New York was 33 in ranking.

The Joint Commission Journal on Quality and Patient Safety found that hospitals that implemented patient safety practices endorsed by the Leapfrog Group reported better quality of care and lower mortality rates.  These results demonstrate that hospitals can clearly improve quality and safety together.


To see how the hospitals in your area rank, CLICK HERE.




Medicare Discloses Hospitals' Bonuses, Penalties Based On Quality  


Medicare recently disclosed hospitals' bonuses and penalties based on quality.  The payment change was created by the federal health law and is known as the Hospital Value - Based Purchasing Program.  It is part of the government's effort to shift away from paying hospitals and doctors based on the quality of care they provide.


Connecticut hospitals come out among the worst in the nation, the data in this link shows.




Legislative Report on Adverse Events
Each year, CT Hospitals are required to report a specified list of adverse events to the state and then, because of our legislation, that report is made public - hospital specific.  Please follow this link and take a look at your own local hospitals (Hospital specific chart starts on page 22).  Reports of wrong site surgeries increased 62%.  These are "NEVER" events and should NEVER happen.  The five hospitals with the highest rate of reported adverse events in 2011 were Charlotte Hungerford Hospital, Sharon Hospital, New Milford Hospital, Stamford Hospital,and the Hospital of Central Connecticut.
It could be that these hospitals just do a better job of accurately reporting.  But that underlines the problem for consumers.  We are told to be participants in our healthcare, but there is so little accurate, reliable information - from the cost of a procedure, to the infection rate of a specific doctor - that the consumer cannot make informed decisions.  These reports are an important way to begin.  Hats off to the hospitals that are reporting honestly.  I just wish we knew which ones they are.  In our original proposed legislation, we included random audits and if unreported adverse events were discovered, consequential hefty fines.  This was pulled from the final bill.  It still could be a way to fund transparency and accountability going forward.

CT Health I-Team reports on Lapses in Medication Care 


A new Yale study addresses mediation errors.  Lisa Chedekel, CT Health I-Team writer reported that a recent Yale study completed by Dr. Horwitz quantifies lapses in medication care.  The doctor looked at 377 patients, ages 64 and older, who had been admitted and then discharged to home.  Of that group, 307 patients,  or 81% either experienced a provider error in their discharge medications or had no understanding of at least one intended medication change.  This study is important because it will allow Yale New Have to make changes that should impact the quality of their medication care and thereby reduce unnecessary harm and confusion for the patient. 



Selling Sickness 2013 will bring together academic scholars, healthcare reformers, consumer advocates and progressive health journalists to examine the global tide of disease mongering.

Conference will include topics pertaining to disease-mongering such as: misleading marketing; ethics in professional education; journalistic standards; social media; over-treatment; new models for drug development and testing; whistleblowers; new conflict of interest areas; health screening policies; impact on public health and our pocketbook.


Selling Sickness 2013
People Before Profits
February 20-22, 2013
Hyatt Regency Washington on Capitol Hill
Washington D.C.




Thank you to Lisa Freeman and to Gus Velez.  Your generosity during our year end fundraising was matched dollar for dollar.