CT Center for Patient Safety
CT Center for Patient Safety Newsletter
May 2013
In This Issue
Medical Error as a leading cause of death
IPFCC Partnerships for Quality and Safety Seminar
Medicare Meltdown
All Payer Claim Database
Jean Rexford 2013   

Why isn't medical error listed in the top ten causes of death in our country?
That questions was recently asked by Bart Windham in the Journal of Participatory Medicine.

"Medical error has been reliably identified as one of America's leading causes of death. The Institute of Medicine's (IOM) landmark report, To Err is Human: Building a Safer Health Care System, concluded in 1999 that 44,000 to 98,000 annual deaths resulted from medical error. Starting in 2003, HealthGrades' Patient Safety in American Hospitals showed that about 195,000 annual deaths result from medical error. In 2010 the U.S. Department of Health and Human Services, Office of Inspector General report, Adverse Events in Hospitals: National Incidence Among Medicare Beneficiaries, found up to 180,000 deaths annually attributable to medical error."


Dr. Pronovost, leading national authority on patient safety has estimated that medical error is the third leading cause of death in our nation.


Rosemary Gibson, author and patient safety authority believes that:

 10% of deaths in this country are the result of preventable healthcare harm which is 250,000 lives unnecessarily lost! 

  • 100,000 from error,
  • 100,000 from infections,
  • 19,000 from unnecessary surgery,
  • 15,000 from radiation over-exposure, and
  • the remaining deaths from medication interaction and chaotic prescribing.

With regard to the leaders of these industries that so inefficiently comprise our healthcare system and say that they are working for the patients, I wonder what precaution their executives take when they are getting healthcare.  What do they know, that we don't, because we have such limited access to safety, quality and the actual costs of care?

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Dear Members,

The pharmaceutical industry continues to lose credibility. After each fine. the industry signs corporate integrity agreements and then returns to their old ways - putting patients and the taxpayer in jeopardy.  Novartis, the American subsidiary of a Swiss pharmaceutical company, last year paid a $422.5 million fine for, the accusation said, providing kickbacks to doctors by providing perks including paying them to sit on advisory boards and speaker fees. In late April this year, they have been charged with providing illegal rebates and discounts to pharmacies based on their success in persuading institutions and doctors to switch patients from other drugs to theirs.  A second suit charges illegal payments to physicians in the form of honoraria to induce them to prescribe the Novartis drugs.

Clearly there is so much money to be made at the expense of patients and taxpayers that these practices, despite civil penalties, continue to be the business norm. It is time to press criminal charges - not only to the pharmaceutical companies but to hold accountable the pharmacies and doctors who take these handouts.  


Lisa FreemanCTCPS board member, Lisa Freeman


I recently attended the Institute for Patient- and Family-Centered Care Partnerships for Quality and Safety Seminar in Annapolis, MD. It was an intense 3 days working with and learning from Institute faculty who shared their experiences, strategies and outcomes that showcase excellence and innovation in partnering with patients and families.

I wanted to learn more about patient-centeredness and how I could relate it to patient safety efforts. I learned many things. First, patient- and family-centered care is care done with the patient and/or family as opposed to patient- and family-focused care which is done for or to the patient and/or family. I learned that patient- and family-centered care leads to higher overall patient satisfaction, lower mortality rates, shorter length of stay and lower cost per case. Shorter stays lead to less time for errors to occur and for patient exposure to hospital acquired infections and other unintended consequences of a hospital stay. Medical error is often traced to a communication breakdown and patient- and family-centered care results in better communication between all members of the patient care team. Quite importantly, it also significantly reduces the readmission rate after a hospitalization.

PFCC is about respect, it is about best practices, it is about common sense and it is about people. When we are all equal partners in our health care, it is clear that health care becomes better care. Connecticut is seriously lagging in advancing towards this model with only a few hospitals embracing the concept. Our efforts at CTCPS will continue to focus on moving Connecticut health care forward towards a better model of care that is patient centered and of the highest and safest quality.

Medicare Meltdown 

Medicare Meltdown:  How Wall Street and Washington Are Ruining Medicare and How To Fix It 
  • Seniors' entitlement to Medicare is not the problem. The health care industry's entitlement to Medicare's money IS the problem.
  • When Medicare was started in 1965, there were no health care companies on the Fortune 100 list. Now there are 15.
  • Identifies "The Seven Habits of a Highly Entitled Health Care Industry" and what they mean for you.
  • Traces the nearly $600 billion a year that Medicare spends, where it goes, and who gets it.
  • Gives a front row seat on the ties between Wall Street and Washington and how they are shaping Medicare's future.
  • Shows how private equity firms and hedge funds are betting on Medicare and what it means for seniors.
  • Explains why private equity firms are buying for-profit hospices - and why so many for-profit hospices have come into the crosshairs of the US Department of Justice.
  • Offers common sense fixes to keep Medicare sustainable that Wall Street and Washington don't want you to know.
CTCPS Research on All Payer Claim Database

Please visit our website for newly published research on the All Payer Claim Database.


With the affordable care act, if the APCD is set up correctly in our state, patients may, for the first time begin to access information on quality, efficacy and safety of care. It will take our state - the land of steady habits - a long time to implement - but it is going to fundamentally change care delivery.



Carlson Forum 2013