When my coauthor, Joni James Aldrich and I first started this endeavor to write “Advocacy Heals U – 15 Keys to Fast Track Results and Emotional Fulfillment”, this past January, we both shared a very strong sentiment and intention, we wanted to write a book that would truly help every single person that took the time to read it. When we first began this project we really had no idea, exactly, how many people and lives our new book would positively touch. As Joni began the writing, we naturally started spending countless hours and days discussing the various aspects of other advocate’s unique journeys. In particular, we focused on the lives and stories of so many of the amazing advocates we had interviewed on Advocacy Heals U, the radio show, over the years who, like Joni and I, had gone through all types of unexpected and unimaginable life events. As we continued our in depth research for this important book, Joni and I really began to see multiple distinct patterns emerge, with respect to people and how they individually responded to the adversity that they encountered in their lives. What we found was incredible! Those people who were able to take their darkest moments in their lives, those unimaginable events that nobody expected, and bring those painful experiences forward in ways that benefit and help others, ALL of them experienced an overwhelming sense of healing, as well as, so many other unexpected blessings. “Advocacy Heals U – 15 Keys to Fast Track Results and Emotional Fulfillment”, references the heartfelt stories of 95 stellar advocates, real people, who have all experienced real Emotional Fulfillment through their advocacy!
On October 22nd, Joni and I had the distinct honor of meeting former First Lady, Rosalynn Carter at a reception held for the Rosalynn Carter Institute’s Annual Global Summit in beautiful Americus, Georgia. On October 23rd, we were humbled to give our very first book presentation and subsequent book signing at the Rosalynn Carter Institute for Caregiving, with the former First Lady actually in attendance! We were told that the special dedication (pictured below) that Joni and I made at the beginning of our book, to the Former 39th President of the United States and the Former First Lady, actually brought tears to Mrs. Carter’s eyes when it was read to her the following day! Below you will find the actual dedication included in our book, the presentation we gave during the event, and a photo of the former first lady and I.
More recently, we have been notified that our publisher, Motivational Press, has submitted our book for a Pulitzer Prize! Through this book we truly hope to inspire advocates all over the world to take control of their lives and begin the hard work of making this world a better place for others in the process.
Better Late than never is what I say! I wanted to post this great article from June about patient safety that was published on Huffington Post. I was very surprised they even mentioned me. Please spread the word about this very important issue facing our nation’s medical facilities.
This was a great way to start the work week! My good friend and esteemed board member of The Emily Jerry Foundation, Ann Oberg, made me aware of some recent articles that ran in Pharmacy Times regarding the vital national issue of pharmacy technician regulation and oversight. The following is an interview I did with Ryan Marotta from Pharmacy Times where we discussed this important topic that affects ALL of us in America! Thank you so much everyone for giving me these opportunities for interviews, public speaking engagements, etc., and most of all, for helping me to honor my beautiful daughter, Emily’s, short life here on earth in ways that ultimately save so many lives!
The following is one of two of the forewords, Joni and I will be using in our new book “Advocacy Heals U – Fifteen Keys to Fast Track Results and Emotional Fulfillment”. Please let us know what you think!
In a remarkable number of cases of medical errors, it’s clear – in retrospect – that there were signs that something was amiss, but they were ignored. The reasons are manifold: I was just too busy, things are always glitchy around here, I didn’t want to be branded a troublemaker by speaking up…. Part of the work of patient safety has been to alert us to this risk, to get us to trust our internal “spidey-sense.” When something seems wrong, we need for advocates to speak up! By doing so, they may prevent either a minor setback or even a major tragedy—such as the loss of two-year-old Emily Jerry.
English psychologist James Reason’s “Swiss cheese model” of error holds that all complex systems harbor many “latent errors,” unsafe conditions that are, in essence, mistakes waiting to happen. They are like a forest carpeted with dry underbrush, just waiting for a match or a lightning strike. On most days, errors are caught in time, much as you remember to grab your house keys right before you lock yourself out. Those errors that evade the first layer of protection are caught by the second. Or the third. When a terrible “organizational accident” occurs — say, a space shuttle crash or a September 11–like intelligence breakdown — post hoc analysis virtually always reveals that the root cause was the failure of multiple layers, a grim yet perfect alignment of the holes in the metaphorical slices of Swiss cheese.
Reason’s model reminds us that most errors are caused by good, competent people who are trying to do the right thing, and that bolstering the system — shrinking the holes in the Swiss cheese or adding overlapping layers — is generally far more productive than trying to purge the system of human error…an impossibility. Advocates garner and implement positive change to otherwise flawed systems because of their determination and vision of a better world.
In this important book, Joni Aldrich and Chris Jerry describe what it is like to lose a loved one because of a medical illness, and the all-too-frequent hazards of our medical care system. Impressively, they have channeled their pain into a series of lessons to help others who—like them—wish to use their experience to try to improve the healthcare system. Their strength, wisdom, and courage are remarkable, and their book will be an essential guide to others who wish to follow a similar path.
~Robert M. Wachter, MD
Interim Chair, Department of Medicine, University of California, and author of the New York Times bestseller: The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age
My amazing coauthor, Joni James Aldrich, and I just received some incredible news today about our new book that its going to print, by our publisher, Motivational Press, in October! The first bit of good news, after reviewing our final manuscript for “Advocacy Heals U -15 Keys to Fast Track Results and Emotional Fulfillment” our book is being nominated for a Pulitzer Prize! If that wasn’t enough…The second bit of good news, we are in the process of working on our book signing tour with our publisher and Joni just called me this morning to let me know that we will be kicking the tour off with a keynote speech and subsequent book signing at the prestigious, Rosalyn Carter Institute’s National Summit, in Americus Georgia, on October 22 & 23. If any our friends would like to attend this very special event with Joni & I, just let us know. If you would like Joni and I to personally sign your copy, we would be honored to do so at either this event, or at any of the events we are planning during our book signing tour (details and formal schedule to follow shortly). Joni and I are so truly excited to start these new chapters in our lives (no pun intended!) If you would like us to visit your small town, or big city, bookstore for a book signing we would love to do it. Just let us know! The following is JUST one great review from my friend Dr. Bob Wachter, there are many more to follow. A big “shout out” to Bob, for all of your continued support our efforts!!!
“In this important book, Joni James Aldrich and Chris Jerry describe what it is like to lose a loved one because of a medical illness and the all-too-frequent hazards of our medical care system. Impressively, they have channeled their pain into a series of lessons to help others who – like them – wish to use their experience to try to improve the healthcare system. Their strength, wisdom, and courage are remarkable, and their book will be an essential guide to others who wish to follow a similar path.”
Robert M. Wachter, MD
Interim Chair, Department of Medicine, University of California, San Francisco, and author of the New York Times bestseller, The Digital Doctor: Hope, Hype, and Harm at the Dawn of Medicine’s Computer Age
Note from Chris: The following is a new article in its entirety that I wrote earlier this month, with my friend and colleague, Michael Wong, from the Physician-Patient Alliance for Health & Safety. The article is titled “CMS Non-Disclosure of Medical Errors Indicates Need for Change in how Healthcare Performance is Measured, Reported in U.S.” This article that Michael and I wrote together, was in response to an article that ran in USA Today titled “Feds stop public disclosure of many serious hospital errors” on August 6th regarding the Centers for Medicare and Medicaid Services (CMS) decision to completely remove important data on “hospital acquired conditions” (HACs) from their Hospital Compare website. The following are my true sentiments on this very important issue that I had posted on Facebook on August 15th.
“I read this article in USA Today last week and it made me absolutely nauseous! In my opinion our government and in particular, the Centers for Medicare and Medicaid (CMS), are very quickly becoming a huge part of the problem, instead of the solution, to preventable medical errors that are senselessly claiming over 440,000 lives every year in the United States. Why would any government regulatory agency involved in patient safety want to stop disclosing ANY preventable medical errors to the public? Could it be that the government feels that “We the people”, can’t handle the real truth? By continually minimizing and “sugar coating” the real statistics and error reporting data that’s gathered, these organizations are actually perpetuating a “culture of denial” instead of positively changing the culture of medicine!
I lost my beautiful two year old daughter Emily to a very tragic and preventable medication error in 2006. Subsequently, I established The Emily Jerry Foundation (www.emilyjerryfoundation.org) to be an active part of the real solution to preventable medical errors. Please help us to honor the millions of people, like Emily, that have been lost to preventable medical errors by joining us and supporting our vital “life saving” cause. By doing this, you can help be the voice of all those who can no longer speak for themselves!”
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If the federal government decided that the nation’s automakers were no longer required to publicly announce recalls of cars equipped with life-threatening defects, the protest from the masses would be deafening.
Yet, a similar scenario is playing out now in the nation’s healthcare industry with relatively little public outcry. As recently reported in USA Today, the federal Centers for Medicare and Medicaid Services (CMS) has quietly stopped publicly reporting when hospitals make certain errors that threaten the lives of patients.
This CMS decision is not only misguided, but it also points to an even more critical issue that exists in our healthcare system today: the need to address the mind-boggling variability in the quality and measures of healthcare provided across the nation.
Currently, CMS, the Agency for Healthcare Research and Quality, the Joint Commission, the Leapfrog Group and the National Committee for Quality Assurance, as well as most states and for-profit companies, such as Healthgrades and U.S. News and World Report, all offer various – and frequently conflicting — performance measures, ratings, rankings and report cards.
Meanwhile, hospitals are creating their own standards and posting their performance on their websites, often with little or no validation of their methodology or data.
This quagmire of information is illustrated in the “2013 National Pharmacy Technician Regulation Scorecard” released by the Emily Jerry Foundation following the heartbreaking death of two-year-old Emily Jerry. It shows variation in training provided to pharmacy technicians.
What all this means is that for patients and their loved ones today, choosing a physician or hospital based on publicly available information has become a daunting and confusing process. Ironically, even though a vast wealth of information is available to them, patients can’t make what could truly be described as informed decision about their care.
How can this problem be solved? For certain, the CMS decision to stop publicly reporting information on life-threatening “hospital acquired conditions” (HACs) is not the answer. When hospitals make mistakes – like leaving foreign objects in patients’ bodies during operations or neglecting to continually monitor patients receiving potentially lethal opioid medication after surgery – the public deserves to be informed about those medical errors just as they are now informed about recalls of defective automobiles. Such information should not – and must not – be swept under the rug.
With that thought in mind, it is imperative that all information and error data be truthfully and honestly disclosed to everyone involved, including the patients receiving medical care. If organizations like CMS, continue to limit and censor the data that is being shared with the public, then we as a society are perpetuating a “culture of denial” and mistrust in medicine, instead of positively affecting the underlying “culture of medicine” and how it is practiced. When this occurs, the public’s trust in modern day healthcare, unfortunately, gets seriously diminished. As a result, the public then loses sight of all the advancements that have been made in recent years, by everyone working together, on all levels, to find comprehensive solutions to preventable medical errors that tragically claim so many lives.
By recent, very credible estimates, preventable medical errors are now the third leading cause of death in the United States, aside from cancer and heart disease. Unfortunately, preventable medical errors are now tragically claiming more than 440,000 lives in America every year (The Journal of Patient Safety “A New Evidence-based Estimate of Patient Harms Associated with Hospital Care”, September 2013 – Volume 9 – Issue 3 – p 122–128). By sighting these astounding numbers of preventable deaths that are occurring, the core objective is to stress the importance of transparently acknowledging the real problem at hand, as well as, the corresponding error data, as shocking as it may be. Subsequently, safeguards and solutions, that effectively save countless lives, can then be implemented as quickly as possible.
These solutions should begin with creating policies that improve – and ultimately create universal standards – for measuring performance quality in our healthcare system.
To create such standards, “Achieving the Potential of Health Care Performance Measures,” a recent report from the Robert Wood Johnson Foundation (RWJF), offers seven recommendations on how to develop better measures; when and how to use measures; and how to ensure the validity and comparability of publicly-reported performance measure data. Described in greater detail in the RWJF report, the recommendations are to:
1. Decisively move from measuring processes to outcomes;
2. Use quality measures strategically, adopting other quality improvement approaches where measures fall short;
3. Measure quality at the level of the organization, rather than the clinician;
4. Measure patient experience with care and patient-reported outcomes as ends in themselves;
5. Use measurement to promote the concept of the rapid-learning health care system;
6. Invest in the “basic science” of measurement development and applications, including an emphasis on anticipating and preventing unintended adverse consequences; and
7. Task a single entity with defining standards for measuring and reporting quality and cost data, similar to the role the Securities and Exchange Commission (SEC) serves for the reporting of corporate financial data, to improve the validity, comparability, and transparency of publicly-reported health care quality data.
Of these recommendations, the last is a game-changer. Creating an entity to serve as the healthcare industry’s equivalent of the SEC would provide patients – who are now forced to swim against seemingly endless waves of competing and often contradictory information – a single source of quality data that has a national consensus behind it.
Should there be an SEC for healthcare? Although this concept will no doubt stir debate, no one can argue that our current systems for measuring performance quality are flawless.
What’s also undeniable is that beyond creating national policies that improve performance reporting – including consistent and accurate information about life-threatening medical mistakes– our nation’s healthcare system needs to take greater steps to prevent those mistakes from happening in the first place.
Fortunately, significant progress on that front is already underway — with myriad action plans and initiatives developed by patient safety experts and advocates groups across the nation, such as these recommendations and this checklist from the Physician-Patient Alliance for Health & Safety.
With national protocols in place to prevent medical errors from occurring – and accurately measuring and reporting them when they do — the lives and safety of literally thousands of patients could be protected each year.
Most sincerely,
Christopher Jerry
President & CEO, The Emily Jerry Foundation
Michael Wong, JD Founder & Executive Director, Physician-Patient Alliance for Health & Safety
* You can view this article where it was originally published on the Physician-Patient Alliance for Health & Safety website by clicking here.
I first became aware of KLAS when I gave a keynote at the Healthcare Information Management Systems Society (HIMSS)
Annual Conference in Orlando, this past February. KLAS Research, based in Orem, Utah, has an extremely important mission statement; “Our mission is to improve healthcare technology delivery by honestly, accurately, and impartially measuring vendor performance for our provider partners”.
KLAS is an independent research firm based in Orem, Utah; established in 1996. KLAS is similar to Consumer Reports, only for Healthcare IT. They conduct over 30,000 interviews per year with healthcare providers to gain qualitative and quantitative data on over 1,000 healthcare IT products within 100+ healthcare IT market segments. They maintain an active database of rankings, performance scores, alerts and blogs to provide vendor transparency to providers on existing technologies.
Similarly, a very key part of The Emily Jerry Foundation’s mission statement is “identifying technology and best practices that are proven to minimize the human error component of medicine.” This is where I saw that both of our organization’s core goals and objectives are in perfect alignment, in striving to always be an active part of the solution to improving healthcare.
I was contacted by the KLAS team, a few months ago, as they were in the process of beginning research on a comprehensive study covering intravenous (IV) compounding technologies that are currently available from various manufacturers. It is absolutely imperative that this vital “life saving” technology be evaluated objectively in an unbiased manner. This is precisely what KLAS does and exactly why The Emily Jerry Foundation is looking forward to establishing a very long, mutually beneficial, relationship between our organizations!
Learn more at klasresearch.com
On the Road to Saving 440,000 Lives a Year!
Click on the image above to view a larger version.
On March 1st of 2006, Emily’s mother and I had to make the most difficult decision of our lives, which was to take our precious 2-year old girl, Emily, off of life support after a preventable medical error. In horrible, unimaginable situations like this, we all respond differently. However, as any father would be, I was completely and totally devastated emotionally. Even with that thought in mind, I still never questioned the existence of God. From that horrific day forward, I knew in my heart that He had to have a plan, I just had absolutely no idea, nor was I ever meant to even comprehend at that point, what exactly God’s plan was for my beautiful little girl’s short life here on earth.
As I frequently mention in many of my speaking engagements and lectures, as Emily’s father looking back over the past eight years, I have really come to believe that Emily’s short life was truly meant to save thousands from the same fate. In retrospect, I am also convinced that Emily’s life was actually meant to be the catalyst for all the positive change in attitudes and opinions on preventable medical errors and how the medical community responds and learns from them. This is precisely why I have always strived with my advocacy efforts, as well as, the programming of The Emily Jerry Foundation to be an active part of the overall “solution” to preventable medical errors, which by recent estimates are claiming more than 440,000 lives every year and are now sadly the third leading cause of death in the United States.
I am extremely pleased to say that the special Guardian Angel logo for the foundation, designed with Emily’s likeness, is very quickly becoming the “Gerber Baby” of patient safety. Most everyone in medicine and pharmacy recognizes it. More importantly to me, they really seem to comprehend the fact that it stands for all of this positive change that is, in fact, occurring in the underlying “culture of medicine” and how it’s being practiced, both here in the United States and abroad. In these ways, Emily lives on, and is truly responsible for saving many lives. My goal is to keep the momentum going forward and continue to inspire those in the medical field to never settle for “good enough” when it comes to patient safety.
When I first established The Emily Jerry Foundation, under these distinct premises, my primary motivation was to begin getting out and speaking to as many caregivers around the nation as possible. I wanted to share with them Emily’s story and the extremely important lessons that have been learned since her passing. My feeling was that the caregivers, hospital administrators, boards of trustees for medical facilities, etc., were the ones who could really impact the changes I was praying for, more quickly than anyone else.
Over the past three years, I have been blessed with the opportunity to speak before tens of thousands of people, all who play an integral part in patient safety in our healthcare system. I have already given more than 75 lectures, keynotes speeches, and presentations on patient safety and ways to reduce preventable medical errors at hospitals and medical conferences around the nation. It is extremely important to keep this wave of enthusiasm for our very important cause moving forward. This is precisely why I believe so strongly that The Emily Jerry Foundation needs to continue to reach and convey our vital messages to as many caregivers and healthcare administrators across the nation, as quickly and effectively, as possible.
According to the American Hospital Association (AHA), we currently have 5, 723 registered hospitals in the United States today. I know it’s a completely unrealistic goal to expect to be able to book the speaking engagements and patient safety symposiums, which have proven very effective over the past few years, at each and every single medical facility in our nation. This is exactly why we have developed The Emily Jerry Foundation’s new “Patient Safety Express” Educational Program, to effectively and efficiently reach, as many of these hospitals, as possible.
My plan is simple. If we can raise enough funds and donations to either purchase or lease a coach tour bus, similar to the one pictured above this article, I am going to make a personal commitment to our cause to live on the road for 12 to 18 months at a time, going to as many hospitals and patient safety functions around the country as humanly possible. Typically, I am only able to conduct roughly two to four speaking engagements and patient safety events per month via commercial airlines. With the “Patient Safety Express”, I will be able to more efficiently cover the entire United States visiting three to five hospitals per week. My very realistic goal then, subsequently, becomes approximately 156 to 260 hospitals and functions per year!
Please join me in this fight by donating toward this very important educational program and our vital “life saving” cause at emilyjerryfoundation.org/donate. If you would like to discuss corporate sponsorship for this program, please contact me directly at [email protected].
Thank You in Advance for your Support!
~Chris Jerry, Patient Safety Advocate
As I posted last month, I was incredibly thankful to be interviewed for Part 1 of Emily’s Story on Mark Graban’s LeanBlog.org. If you are new to the site or missed that episode, click here to listen to Part 1.
Mark recently released Part 2 of our conversation which covers many topics including: overhauling systems vs. blaming individuals, pushing for a comprehensive national Pharmacy Tech policy, Public forgiveness of Eric Cropp, and much more! Click here to listen to Part 2 of my interview on the LeanBlog.org Podcast.
Mark’s blog is a great place to learn innovative information about best practices in medicine so please share with your network. As always thanks for your continued support!
The Emily Jerry Foundation is determined to help make our nation’s, world renowned, medical facilities safer for everyone, beginning with our babies and children. We are accomplishing this very important objective by focusing on increasing public awareness of key patient safety related issues and identifying technology and best practices that are proven to minimize the “human error” component of medicine. Through our ongoing efforts The Emily Jerry Foundation is working hard to save lives every day.
Last Updated: August 1, 2024 by ejfadmin
How our “Life Saving” Partnership with RxTOOLKIT Began
In the summer of 2014, Chuck DiTrapano, a highly esteemed pharmacist from Reading, Pennsylvania reached out to me via email. The following is an important excerpt from Chuck’s poignant message that truly made me believe that we had been brought together for a very distinct purpose.
Then Chuck began to share with me his heartfelt story of how his advocacy journey, as well as, his life experience, led him to establish a very successful family owned and operated business called RxTOOLKIT. As an expert pharmacist, he went on to explain in detail his true determination and effort to prevent tragic medication errors like the one that claimed my beautiful daughter Emily’s life in 2006. Just like me, Chuck was horrified at the thought that preventable medical errors are now the third leading cause of death in America, claiming over 440,000 lives each and every year! As a leading pharmacist, he also knew that medication errors were responsible for the largest percentage of these preventable deaths. With that said, the following is the story of how RxTOOLKIT was actually born, in Chuck’s own words, and was taken from the early email correspondence we had regarding this important issue.
On November 11th of 2014, I flew to Philadelphia to meet Chuck, in person, and to give two lectures at Reading Hospital that he had arranged. The whole experience was absolutely amazing! What made it so special was the simple fact that I felt an immediate bond with Chuck because he appeared to be on exactly the same path I was, the guy was on a mission to save lives from preventable medication errors and ultimately put a stop to all of these senseless tragedies that occur with far too many patients, each and every year! Furthermore, he proved to me he was “walking the walk” when I was given an extensive tour of Reading Hospital. I subsequently learned that RxTOOLKIT software was deeply integrated into virtually every aspect of pharmacy operations at this enormous healthcare facility and had been clinically proven to prevent medication errors for almost ten years!
Shortly after my visit in 2014, Chuck and I began discussing, in detail, how our two organizations could collaborate and partner on the development of a pharmacy technician eLearning training program that would significantly improve the core competency of ALL pharmacy technicians across the United States if they enrolled and participated in the program for continuing education credits (CE). Hence, RxTOOLKIT eLearning was born (in BETA now!).
Please click here to read the very profound dedication they just made to my little Emily’s legacy!! As her Daddy, It’s in ways like these that I believe my beautiful baby girl will always live on!! I am so very proud of her! https://rxtoolkitelearning.com/about/dedication/