CT Center for Patient Safety
CT Center for Patient Safety Newsletter

May 2014
In This Issue
Empowering Connecticut's Newly Insured...Identifying the Gaps in Accessing Health Care
Cost of Treatment
Summary of OIG Reports on Adverse Events
Drug Abuse in the Medical Community
Misdiagnosed: Docs' Mistakes Affect 12 Million a Year
Empowering Connecticut's Newly Insured - 
Identifying the Gaps in Accessing Health Care

Connecticut Center for Patient Safety will host a Roundtable Panel discussion with national and state experts to learn more about the experience of Connecticut's newly insured.  Our discussion will focus on what patients need to know in order to make the most of their new health insurance and health care.



Wednesday May 14th  at  9:30 am to 12:00 pm

Legislative Office Building

Room 1D

300 Capitol Avenue

Hartford, CT




Randi Redmond Oster, President,  Well Path Press



Luis Diez-Morales, MD-Medical Director Saint Francis Center for Health Equity                      

Venton B. Forbes, Executive Director at FaithCare

Steve Glick, Pres. Chamber Insurance Trust

Aline Holmes, DNP(c), RN   New Jersey Hospital Association/NJ Hospital Engagement Network

Todd Meadows, Urban League of Greater Hartford Employee , Newly insured Community Member

Jacqueline Ortiz-Miller, Community Health Worker/Health Educator

Doris Peter, Director Consumer Reports Health Ratings Center 



For more information, contact Jean Rexford at: [email protected] or 203.247.5757 



This Roundtable is sponsored by 

the CT Center for Patient Safety

and is made possible by a generous grant from

 the CT Health Foundation.

Plan ahead!!

According to several studies, there is a spike in serious medical errors during the month of July . This spike is referred to as "The July Effect" and is attributed to the influx of new interns and residents in teaching hospitals.

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Dear Members,

Recently, in  a New York Times article, "Cost of Treatment May Influence Doctors" Andrew Pollack wrote that some of the most influential medical groups in the nation are recommending that doctors weight the costs, not just the effectiveness of the treatments, as THEY make decisions about patient care.

These influential medical groups did not even talk about the importance of including patients in decision making!  Of course, we want to be involved and of course costs can influence our decisions.  I have spent a great deal of time this winter working with individuals and institutions framing patient engagement and decision making.  Someone is not getting the memo.  Doctors should always consult with the patient and include them, and their families or caregivers, in the decisions.  

If you have a story about your doctor including you - not just treating you - we want to hear it.



 Summary of OIG Reports on Adverse Events.

  •   "During a 1-month period, OIG found that 13.5 percent (of Medicare Patients) experienced adverse events and that for 1.5 percent of beneficiaries, these adverse events contributed to their deaths. An additional 13.5 percent of beneficiaries in the sample experienced temporary harm as a result of their medical care, bringing the total percentage of beneficiaries experiencing instances of care-related harm to 27 percent. Nearly half (44 percent) of these adverse or temporary harm events were preventable." OIG determined that the costs to Medicare associated with adverse and temporary harm events totaled an estimated $324 million for 1 month alone. This would equate to an estimated $4.4 billion per year." Read more about this report here.
  •  "Yet, OIG found that hospital staff did not report 86 percent of events to incident reporting systems." "Just 12 percent of the temporary harm or adverse events that occurred in hospitals met State requirements for reporting; in other words, only 35 of the events in the sample were required to be reported to the State reporting systems. Hospitals actually reported just three of these events, all in Pennsylvania. Many of the events not reported as required involved serious harm, including six patient deaths."  Read more here.    


"America's prescription drug epidemic reaches deep into the medical community. Across the country, more than 100,000 doctors, nurses, technicians and other health professionals struggle with abuse or addiction, mostly involving narcotics such as oxycodone and fentanyl. "

We have begun to work on this important issue in our state.  The Medical Society has been convening stakeholders to develop strategies.  

Misdiagnosed: Docs' Mistakes Affect 12 Million a Year


Misdiagnosis, affects up to 12 million Americans a  year (1 in 20 patients). According to a study recently released in the British Medical Journal of Safety and Quality: " Combining estimates from the three [previous] studies yielded a rate of outpatient diagnostic errors of 5.08%, or approximately 12 million US adults every year. Based upon previous work, we estimate that about half of these errors could potentially be harmful."

 According to patient safety expert Dr. Hardeep Singh, of those misdiagnosis mistakes, about 6 million could potentially cause harm.  Dr. Singh, is the first to provide robust population-level data on the impact of the problem in outpatient settings.  For more on the NBC News report on this story, click here.


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