CT Center for Patient Safety Newsletter

December 2015

We are nearing the end of our annual fundraising drive. One of our big projects this year is educating medical students, nursing students and other health science students about patient safety and the patient experience.

A generous donor has agreed to match every single dollar you give

during this drive. Please take advantage of this matching gift and

DOUBLE YOUR DONATION TODAY!

In This Issue

Looking for Guest Writers

CT Adverse Medical Events & the Leapfrog Hospital Ratings

The Health of our Healthcare System

Brand Name v. Generic Drugs

Open Enrollment is Underway

December Health Hint

Would you like to contribute to our newsletter as a guest writer?

If you would be interested in writing an article sharing your healthcare story or something that you feel would be of interest to our readers, please contact us with your idea. We are always looking for interesting perspectives that will inform our readers and add to their knowledge of our healthcare system.

The 2015 CT Department of Public Health Report on Adverse Medical Events and the Leapfrog Group Ratings

For 2014 the number of adverse events reports (n=471) was 12% lower than the preceding year

(n=534). The most common adverse events among reports were pressure ulcers acquired after admission to a healthcare facility, falls resulting in serious

disability or death, perforations during open, laparoscopic, and/or endoscopic procedures, and

retention of foreign objects in patients after surgery. These four categories accounted for

89% of events reported in 2014. Each of these categories represented at least a small decrease from the prior year; however these are events that should not occur at all. Under Connecticut's Adverse Event reporting law, facilities are required to submit a Corrective Action Plan to DPH for each reported Adverse Event. After examining an adverse event report, which includes a Corrective Action Plan, the DPH Healthcare Quality and Safety Branch determines whether to initiate an investigation.

This year, the report included information resulting from a patient-initiated voluntary online survey of adverse medical events: the perspective of 696 injured patients and families. Published by Frederick S Southwick, Nicole M Cranley, Julia A Hallisy in BMJ Qual Saf doi:10.1136/bmjqs-

2015-003980 Published Online 19 June 2015, they found that "Harm was most commonly associated with diagnostic and therapeutic errors, followed by surgical or procedural complications, hospital-associated infections and medication errors, and our quantitative results match those of previous provider-initiated patient surveys.

Qualitative analysis of 450 narratives revealed a lack of perceived provider and system accountability, deficient and disrespectful communication and a failure of providers to listen as
major themes. The consequences of adverse events included death, post-traumatic stress, financial hardship and permanent disability. These conditions and consequences led to a loss of patients' trust in both the health system and providers. Patients and family members offered suggestions for preventing future adverse events and emphasized the importance of shared decision-making."

The Hospital Safety Scores published by The Leapfrog Group assessed 25 of Connecticut's hospitals. Their ratings use national performance measures from the Leapfrog Hospital Survey, the Agency for Healthcare Research and Quality (AHRQ), the Centers for Disease Control and Prevention (CDC), the Centers for Medicare and Medicaid Services (CMS), and the American Hospital Association's Annual Survey and Health Information Technology Supplement.

According to their website, taken together, those performance measures produce a single score representing a hospital's overall performance in keeping patients safe from preventable harm and medical errors. The Hospital Safety Score includes 28 measures, all currently in use by national measurement and reporting programs. The Hospital Safety Score methodology has been peer reviewed and published in the Journal of Patient Safety.

Connecticut's hospitals garnered Four (4) A's, Four (4) B's, Fourteen (14) C's and Three (3) D's.

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Dear Members,

I hope that everyone had a Happy Thanksgiving.

At this time of the year when we give thanks for many things, it is somewhat bittersweet for many people who I have met through my work here at the Connecticut Center for Patient Safety. As an organization whose mission is focused on making healthcare safer, we often hear from people or their family members who have experienced medical harm in their healthcare encounters. They have experienced some of the 1.7 million hospital acquired infections each year or are perhaps among the 400,000 people who die each year from medical error. They put their trust in a system that doesn't always serve them well. Our thoughts are with them at this time.

The dial is slowly beginning to move towards a safer system with better outcomes, but admittedly it is not moving fast enough. Many hospitals are now using tools such as time outs, pre-surgical huddles and checklists to reduce medical harm. It is well known that hand washing and other strategies, when followed by clinicians and patients alike, contributes significantly to reducing infections. Our website has many patient resources so that you, our reader, can learn what to expect and what you can do to be more engaged in your own care. CTCPS also offers workshops to groups who want to learn how they can be more engaged, informed patients. Contact us through our website if you are interested in organizing an event. Finally, we continue our educational outreach to health care providers and future providers to share the patient experience and strategies with them for avoiding medical harm.

Zero is the number that we want to see when it comes to avoidable medical harm. Other healthcare advocates, our organization and I will not stop our efforts to get there and will continue to represent the patient perspective and voice in all that we do.

Lisa Freeman

The Health of our Healthcare System

Did you know that for most of the leading causes of death, mortality rates are higher in the U.S. than in comparable countries, but that mortality rates for breast and colorectal cancer in the U.S. are lower than in comparable countries?

In a video written and produced by the Kaiser Family Foundation, the US Healthcare system is assessed in comparison to systems in other high-income developed countries. This video assesses four key areas: how healthy we are, the quality of care we receive, how much it costs, and how accessible it is. Watch this 3�-minute video to learn much more!

Brand Name Placebos Are More Effective Than Generic Placebos. For Real!

In a study published in October's Health Psychology magazine, pain reduction for headache pain following the use of brand name and generic labeled tablets was studied. The twist was that � of the people in each group received placebos. What do you think the results were? In this Healthcare Triage News Video, this interesting study is explained.

Open Enrollment is Underway

Open enrollment is the period when people can enroll in a health insurance plan for the coming year. For 2016 coverage, the Open Enrollment Period is November 1, 2015 - January 31, 2016. People may qualify for Special Enrollment Periods allowing them to enroll outside of Open Enrollment if they have certain life events, like getting married, having a baby, or losing other coverage.

Many people are not certain of the considerations that should guide them to choosing the best plan for their needs. Research shows that consumers make many mistakes and often end up paying more than they need to. One of the first things that should be considered is how much more you will pay per year in order to have a lower deductible (the amount you owe for health care services your health insurance or plan covers before your health insurance or plan begins to pay). You should also consider how you expect to use your insurance, what your pattern or expectation of medical expenses will be and what your anticipated out-of-pocket (includes deductibles, co-insurance, co-payments, or similar charges and any other expenditure required of an individual for a qualified medical expense) costs will be. Another consideration that should be factored in is how much risk you want to take for the unexpected medical emergency and how the various plans will cover you and what your maximum out-of-pocket exposure is.

Many people were found to misunderstand plan features and costs. According to a NY Times article, even when they had plan details in front of them, in a study done by a professor at Carnegie Mellon, only 40% of the people studied could identify how much an MRI would cost them, and only 11% could determine what a four-day hospital stay would cost them. When subjects who said that they understood specific insurance terms were tested on their understanding of the terms, only 28% could correctly answer their understanding of the term "co-pay" and 41% couldn't define "maximum out-of-pocket."

To help you better understand the vocabulary associated with health care and some of the considerations, the Centers for Medicare & Medicaid Services has published a booklet, "A Roadmap to Better Care and a Healthier You." ConsumerReports has a webpage with a health insurance buying guide. It includes sections on: understanding how insurance works, choosing the right health insurance, and maximizing your health insurance plan.

December Health Hint

With the holiday season upon us people are feeling more stress in their daily lives.

According to experts, to help manage stress, pay attention to your level of stress, which may increase during busy times such as holidays. Stress comes in many forms, and can have a negative effect on health if it continues too long or feels overwhelming. Many tools are available to help you manage and reduce your stress.

Basic Stress Management Suggestions

Physical Activity-Take a brisk walk or engage in other physically demanding activities. This may reduce your stress. Regular physical activity is best.
Problem Solving-Learn problem solving skills as this can often improve your ability to cope. You might be able to find locations that offer classes or information sessions on problem solving skills. There are also web-based problem-solving programs available.
Relaxation Training-Learn relaxation and mindfulness skills. These skills can assist you to manage the arousal that is associated with stress, and daily relaxation may protect you from at least some of the consequences of stress.
Expression-Speak up in respectful ways. Sharing thoughts and feelings in an assertive and respectful manner can sometimes help buffer stress. Keeping those thoughts inside can increase your stress.
Time Management-List what needs to get done, make plans for addressing issues, and stick to the plan. There are several self-help books on time management at libraries and book stores.
Positive Thinking-Stress is often associated with negative, self-critical thinking. Focus your attention on positive thoughts about yourself, favorite songs, poems, favorite prayers, or hobbies.
Pleasant Activities-You may be experiencing the effects of stress if you are not making time for fun in your life. Plan to have regular, enjoyable activities and see if this buffers your stress.