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Tell Us Your Story

Have you had an experience you would like to share with us? The strength of the CT Center for Patient Safety is the reality of what happened to you or a loved one. By adding your voice to ours, we grow stronger.

Please answer the following questions to the best of your ability, with respect to either your own experience or the experience of your loved one. Thanks for taking the time to do this.

1. What year did this happen?
2. Was it in a: Doctor’s office? A hospital? Other?
3. Describe your experience in your own words:
4. Name of hospital or doctor or facility:
5. Have you experienced a medication error? Yes No
6. Were you misdiagnosed? Yes No
7. If you contracted an infection while hospitalized
    What area of the hospital?
    Was it following surgery? Yes No
    How many days did the infection add to the hospital stay?
    Did you find out about the infection after you left the hospital? Yes No
    What was the name of the infection?
    Do you know where the infection started? Catheter? Surgical site?

Please provide the following basic contact information so that we can call you to find out more about your experience. Your personal story will help us move this issue forward!

First Name:
Last Name:
Email:
Street:
City/State/Zip:
Phone:

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