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CTCPS in the News

With providers moving to electronic medical record systems, they often still don't "talk" to each other. Just think how much safer your care could be if all of your providers could see the same complete data and know what each other is doing. There would be less duplication of testing, everyone would be on the same page, and we would expect that much less information would fall through the cracks. Read Lisa Freeman's comments in this CT Mirror article, Can the state build a better system to get your medical records to your doctors?.

The current legislative session in Hartford holds promise for improving the safety and quality of health care in Connecticut. There are a number of bipartisan bills introduced by Senator Looney and Senator Fasano, as well as other Senators that call for transparency of infection rates, health care costs, prices and quality information as well as a bill to allow for dispute resolution of surprise billing and emergency services. You can read Lisa Freeman's Op-Ed in the CT Mirror regarding the proposed legislation here.

The Public Health Committee of the Connecticut General Assembly held a hearing on March 11th for public comment on a number of bills to address the changing health care landscape in Connecticut. Some of the bills address the need for transparency of cost and quality; a theme that has broader support among different stakeholders. In the CT Mirror's article, In controversial health care bills, some agreement on transparency, Jean Rexford shares her thoughts on the need that Connecticut residents have for this information to be available so that they can be more informed and engaged in their healthcare.

Patient-Centered Care involves healthcare systems embracing a culture and a philosophy that includes and considers patient's perspectives in everything that they do. Lisa Freeman wrote an article for Planetree's Planetalk publication titled: A Call to Action: It's Time to Break Another Glass Ceiling. In it, she talks about the missed opportunity when hospital, long-term care facilities and physician practice governing boards do not have patient members on them. After all, this represents the ultimate partnership with patients and their perspective should become part of business as usual.

Given all of the current technology, strategies and tools that are available to prevent these occurrences, it is unacceptable that foreign objects are still being left in surgical sites and that wrong-site surgeries are still occurring," says Lisa Freeman, executive director of the nonprofit Connecticut Center for Patient Safety. Laura Landro's article in the Wall Street Journal, How to Make Surgery Safer, points out that there are still 4,082 malpractice claims for mistakes that should never occur such as operating on the wrong body part. She also discusses various strategies that are working in Connecticut hospitals and others across the country to reduce errors and bring about improvements in healthcare outcomes and quality.


Jean Rexford recently spoke with Eric Parker, Chief Investigative Reporter for the Channel 3 I-Team (WFSB). His report on hospital acquired infections, including his conversation with Jean was aired on November 3rd, in two segments. If you were unable to watch it when it aired, the links to the two-part report on Connecticut's WFSB Channel 3 are: Part I and Part II


Following the November release of the CT state infection report and the January release of the state’s Legislative adverse events report, CTCPS Executive Director Lisa Freeman’s op-ed, CT hospitals must do more to prevent errors and patient harm, was published in the CT Mirror on January 14, 2015.  The results of these reports show that Connecticut’s hospitals are performing very badly.  CT ranked 50th with the highest percentage of hospitals of any state exceeding the infection standards set by the U.S. Centers for Disease Control and Prevention.  The rate of adverse events reported also increased over the prior year with wrong site surgeries and retained foreign objects - known as "never events" still occurring in our hospitals.


With Kaiser's announcement that 721 hospitals in the United States will witness cuts in their Medicare payments by 1 percent due to their high rates of hospital-acquired conditions, Jean Rexford has been called upon for her expert opinion by several media outlets.  The stories where she shared her thoughts can be found in the National Monitor's story, Funding for U.S. hospitals steadily declining and in the CT Post's story, High infection rates may mean funding cuts.


Under a grant from the CT Health Foundation, CTCPS researched the barriers that Connecticut’s newly insured are facing in obtaining health insurance and medical care. We recently met with the editorial board at the Hartford Courant and this November 12, 2014 editorial is the outcome of our shared information. Click here to view the full report.


Jean Rexford recently spoke with Eric Parker, Chief Investigative Reporter for the Channel 3 I-Team (WFSB). His report on hospital acquired infections, including his conversation with Jean was aired on November 3rd, in two segments. If you were unable to watch it when it aired, the links to the two-part report on Connecticut's WFSB Channel 3 are: Part I and Part II


We are excited to share the official launch of The Connecticut Partnership for Patient Safety (CPPS). This collaborative endeavor has set its focus on patient protection and patient safety by reducing patient harm caused by the State’s healthcare delivery system through collaborating with and enhancing the many patient safety/quality improvement initiatives already underway. Jean Rexford, representing the patient voice, sits on the Board. Read the full press release here.


On May 14th the Connecticut Center for Patient Safety (CTCPS) hosted a Roundtable Panel discussion, made possible by a generous grant from the CT Health Foundation, with national and state experts to learn more about the experience of Connecticut's newly insured. It was a tremendous success and generated rich and multi-faceted discussions about the current issues facing this population. More about the event can be read in an article published by the CT Mirror, Obamacare got them insurance, but patients still face barriers to care. What we learned will be combined with extensive research to ultimately empower Connecticut's newly insured by identifying and finding ways to close the gaps in accessing health care.


There are databanks that track bad doctors. The National Practitioner Databank and the Healthcare Databank were created for this purpose. Recently, the Connecticut Supreme Court rendered a decision in which the justices ruled that neither database can be accessed by the public under freedom of information laws. As Jean Rexford points out in an article titled "The Case Of The Doctored Sperm Donation," it is good that these databanks give "hospitals and medical schools access to the physicians' histories, for hiring purposes". But she goes on to state that "medical consumers should be able to access similar information."


February 4, 2014, Today’s guest post on the Connecticut Health Foundation blog was written by Jean Rexford, Executive Director of the CT Center for Patient Safety. "How can so many bright people not see what I see? Years ago, a PBS special featured how different animals and birds saw the world through their unique set of eyes. Eagles, chameleons, houseflies have a unique lens that allow them to see what they need to so that might survive in a complex world. I think of this often as I sit at multiple tables, in Connecticut and on national committees. Why don’t the other people at the table know what I know?" Read more.


Listen to CTCPS Executive Director, Jean Rexford's recent interview on WTIC's "Face Connecticut" hosted by Sam Gingerella which aired Sunday morning, November 17th. In this discussion, Jean talked about the changing face of hospital care, infection rates and other medical harm, the patients’ role and voice in healthcare, and how CTCPS is engaged in representing and protecting the patient on a local and national level.


This article, 10 Tips for a Better Hospital Stay in October's Healthylife magazine, to which Jean Rexford has contributed and is quoted in, talks about 10 steps you can take to better anticipate and prepare for a trip to the hospital. Taking an active role in your care can help to ensure a positive hospital experience. With some smart preparation, you can feel confident that you've done your best to create a situation that will lead to a speedy and healthy recovery.


An article, State's Doctor Discipline Process Hampered by Delays, authored by journalists Colleen McKown and Lisa Chedekel, in which Jean Rexford is quoted, can be found in both the CT Post and on the C-Hit Websites. It discusses the profound delay from the time that a complaint is filed about medical care and the time that a disciplinary decisions is rendered can range from one year to as long as four years. During this delay, the provider continues to practice. 


The State of Connecticut is currently engaged in the development of a database that will consolidate – for the first time – data for health encounters across every provider, facility, plan, and health claim payer. The All Payer Claim Database (APCD) is the federally funded underpinning for evidence-based reforms that can influence economic and equity analysis, health systems quality and outcomes benchmarking, and consumer transparency. This is an important project of inestimable value to our state. Looking at information gathered from ten states have already established APCDs, we endeavored to translate what we learned into recommendations for consideration in our state. Our findings, in a study done by Jean Rexford, Ellen Andrews, PhD and Brenda Shipley, MA can be read here.


AIG Study Shows Hospital C-Suite and Risk Managers Struggle with Maintaining Patient Safety. View


Jean Rexford is quoted in this C-Hit article titled Hospitals Mobilize To Tackle Alarm Fatigue which discusses the phenomenon known industry-wide as alarm fatigue where medical devices with built-in alarms – such as heart monitors, infusion pumps and ventilators – designed to alert caregivers that patients are in danger could potentially put patients at risk because caregivers are desensitized by the sheer number of alerts and false alarms.


Jean Rexford testified at a hearing of the US Senate Special Committee on Aging on Next Steps for Patient Safety: Assuring High Value Health Care Across All Sites of Care, held by Senator Richard Blumenthal of Connecticut. It was well attended and CTCPS will continue working with Senator Blumenthal on the issues that were raised this afternoon. Read Jean's testimony.


Checklists, teamwork minimizing mistakes in medicine. View 

Listen to CTCPS's own Jean Rexford discussing Patient Safety on WNPR's Where We Live from March 6, 2012 show. Listen 

Safety Advocates Unveil Device Safety Agenda, Ramp Up Lobbying - InsideHealthPolicy.com by Nanci Bompey - Wednesday February 15, 2012 View

Safe To Be Sick in the National Journal By Maggie Fox Updated: January 26, 2012 10:25 am View

Hospital Errors Persist, State Probes Rare by Lisa Chedekel on Jan 29, 2012 9:00 pm View

Blumenthal Sponsors Bill To Protect Patients From Unsafe Medical Devices View

CTCPS joins 30 other organizations in a call for Safe Drug Manufacturing Reforms Wednesday, November 30th, 2011 View

Red flags raised with alarming medical board decisions - Debra Friedman, Staff Writer View

Disciplines Docs Practice Freely In State View

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Healthcare in the News

Recently, the death of a  53-year-old father of eight children and grandfather of 10 was highlighted in the media.  It involved a surgery that he received at an outpatient surgical center in Trumbull, CT.  According to the family, the surgery was too "complicated to be performed at an outpatient facility, and his father should have been treated at a hospital."  This issue is a very important one as the landscape of hospitals and health care are changing and it warrants further discussion and consideration.  An article about this was published in the CT Post on April 20, 2015.

Nearly 9 in 10 US adults now have health insurance.  View

The Connecticut Partnership for Patient Safety forms board.  View

How did your hospital rate on infections compared to national benchmarks? C-Hit easy to use tool can be found here.

Tenet ends bid to acquire five Connecticut hospitals View

Knee Replacement Device Unapproved, but Used in Surgery View

Anthem says hackers stole customers’ personal information View CT Mirror View NY Times

Here's why healthcare should be talking about net neutrality View

Disclosure and Apology: A Win-Win for Patient Safety and Medical Liability? On July 28, 2014, Jean Rexford participated in a discussion about medical liability reform and how to protect patients who experience adverse medical events and help practitioners provide the highest quality care possible. Their discussion was moderated by the Alliance for Health Reform, included representatives from various stakeholder groups and can be viewed here.

The Battle Against Misdiagnosis: American doctors make the wrong call more than 12 million times a year View

Even Small Medical Advances Can Mean Big Jumps in Bills View

Medical fraud in CT costs feds millions of dollars View 

An Ounce of Evidence | Health Policy View

FDA Failed to Track Substandard Generics, Congress Told View

In A Major Shift, Medicare Wants Power to Ban Harmful Prescribers View

Clean Sweep: Hospitals Bring Janitors to the Front Lines of Infection Control View

Medicare To Punish 24 State Hospitals For High Readmissions View

Aetna withdraws from state's health insurance exchange View 

Bone-Chilling Mistakes Hospitals Make And Why They Don't Want You To Know View 

'Top' hospitals aren't always tops, new report finds View 

Scientists Seek to Rein In Diagnoses of Cancer View 

NY, NJ cardiologist admits record $19M fraud; thousands of patients got unneeded treatment View 

Are Hospitals Less Safe Than We Think? View 

Hospitals 'Unaccountable,' says surgeon in new book View 

Far more could be done to stop the deadly bacteria C. diff. View 

MRSA on the Rise: Infections Have Doubled in 5 Years View

Anemia drugs made billions, but at what cost? View 

Big Pharma's Big Fines View

FDA To Fund Controversial Research Foundation View

Troubling Flaws in a Heart Device Shake Implant Makers. View

Drugmakers have paid $8 billion in fraud fines. View

Conn. Law Nixing Legitimate Malpractice Lawsuits has led to many cases being dismissed View

Pfizer Inc. must pay more than $45 million in damages to two women who blamed the company's menopause drugs for their breast cancers View

Patients Can Protect Themselves Against Hospital Errors and Infections View

Without Autopsies, Hospitals Bury Their Mistakes View

Bill Would Require More Monitoring of Implants View

Doing Things Right: Why Three Hospitals Didn't Harm My Wife View

CT DPH - Legislative Report To The General Assembly ADVERSE EVENT REPORTING View

Feds to allow use of Medicare data to rate doctors, hospitals and other health care providers View

Patient Safety Advocates Start New England Watchdog Group View

Medical Professionals Fail to Report Near-Misses View

Will $1.2 Million a Day Convince Congress to Buy Big Pharma's Rx for Change? View

Jurevicius sues Browns over staph View

EDITORIAL: State should ban gifts to doctors View

Bill would limit 'gifts' to doctors View

End Drug Company Gifts To Doctors View

Drug Company Gifts Are Bad Medicine View

What You Don't Know About a Drug Can Hurt You View

Lack of federal-level hospital oversight leaves patients suffering View

NPR doc didn't disclose pharma payments View

Kaiser Daily Health Policy Report View

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Becoming a More Empowered Patient

First, we have chosen to share a video by Consumer Health Choices: Talking With Your Doctor. In it you will see how preparing for you appointment can make a difference.

We have chosen a second video by the National Patient Safety Foundation: AskMe3, to share with you. Here, you learn that there are three important questions to ask your doctor whenever you see him or her.

Finally, we are sharing a series of videos by Dartmouth-Hitchcock:
Self-Advocacy: The Empowered Patient,
Self-Advocacy: Preparing for your Visit,
Self-Advocacy: Why It's Important To Share and
Self-Advocacy: Doing Research.

For the complete story, please click here

5 Things to Know

  1. What you need to know in the Hospital
  2. 15 Steps You Can Take To Reduce Your Risk of a Hospital Infection
  3. Selecting Doctors & Hospitals
  4. What to do to avoid medication error
  5. AHRQ Director Helps Consumers Navigate the Health Care System in a New Advice Column on the Web

You've Suffered Medical Harm - Now What Do You Do?

According to a recent article published by ProPublica titled: So You’ve Become a Patient Safety Statistic – Now What? by Marshall Allen there are six things to do….

  1. Get a copy of medical records.
  2. Make sure the incident is reported internally.
  3. If the patient has died, order a forensic autopsy.
  4. Consider calling an attorney.
  5. Meet with the doctor and hospital officials.
  6. Report the incident to regulators, who can investigate.

For greater detail and more important information, please read the full article.