Most of the public is completely unaware of this fact and many people in the medical community, who are cognizant, are in complete denial!

On March 1st 2006, five days after my beautiful daughter Emily’s second birthday, my wife and I had to make the worst decision of our entire lives, to take our little girl off of life support. That horrific day will always remain permanently burned into my memory and it haunts me every single day. It was only by the Grace of God and His new little angel Emily that truly saved me from myself in the years that followed this unimaginable tragedy.

It was also on that day, that I knew in my heart that my life had drastically changed forever. I absolutely understood that there was no way to bring my sweet Emily back, however, I also knew that I could find out exactly what happened to her and, subsequently, find ways to ensure that other babies, children, and their families, didn’t suffer a similar fate. I still continue to have, and have always had, the utmost respect for modern day science and medicine. After all, it was modern day medicine and the advances that have been made in research and development of new leading edge treatment methods that had actually cured my Emily of an extremely life threatening, horrible, tumor that, just 10 or 15 years prior would have proven to be fatal for any patient with that particular diagnosis.

Shortly after Emily’s heartbreaking death from a horrible medication error, I immediately began researching preventable medical error, desperately trying to educate myself on why these tragedies occur at such an astonishing number in the United States and globally, each and every year. To me, as well as many others, these annual numbers of deaths that had been reported in historic studies like “To Err is Human” in 1999, by the Institute of Medicine (IOM), were completely unacceptable and did not have to happen in the first place. Again, in my opinion, they are called preventable medical errors for a reason. They really are preventable! When the IOM first introduced this landmark study in 1999, they tried as best as they could to very accurately assess the number of deaths that occur every year in America. The number that they were able to quantify, at that time, was over 100,000 lives each and every year. I was completely shocked to learn that this many people died every year just like Emily did!

In the years following this initial IOM report, through the use of what are called “global trigger tools”, SBAR (Situation, Background, Assessment, and Recommendation) tools, etc., the new numbers of estimated deaths in the United States from preventable medical errors, began to climb substantially and double to over 200,000 lives lost every year in America.

I began to think to myself that either number was horrific and senseless. There were so many questions that I had. I started to wonder why the total number of deaths had doubled? Were there really twice as many people dying from preventable medical error a decade after the IOM’s report, or was the core of the problem in the accuracy of the reporting? If this was the case, was the real number of deaths that occur annually in the United States even larger than the 200,000 that was being used? Then I began to ponder the question, that in 2006, when Emily died, would she have been included in those numbers? If not, her short life wouldn’t have even amounted to an accurate statistic. Was that what everyone was telling me? As her father, my biggest fear was that my little Emily would have been completely forgotten and her short life wouldn’t have even been counted, as if she had never even been born. What about all of the other lives that had been lost so tragically from preventable medical error? All because we as a society and the medical community had no way of accurately counting the real number of lives lost to preventable medical errors. As you can probably already tell, this whole notion has never sat very well with me. As I’m sure you will agree, this is definitely not the way we should be honoring our loved ones, especially after their lives had ended so abruptly and unexpectedly!

A retired NASA scientist by the name of John James, who heartbreakingly lost his 19-year old son to multiple preventable medical errors as a result of cardiologist’s mistakes at two separate medical facilities in Houston, also dedicated the remainder of his life’s work to honoring his son’s life by improving hospital safety and founding an organization called Patient Safety America. Flash-forward to September of 2013, John authored a comprehensive study that had its conclusion published in the Journal of Patient Safety called “A New Evidence-based Estimate of Patient Harms Associated with Hospital Care” (September 2013 – Volume 9 – Issue 3 – p 122–128). This ground breaking study put the new number at 440,000 lives lost in America every year due to preventable medical error, making preventable medical error the third leading cause of death, aside from heart disease and cancer!

Shortly after this important study was released, I began presenting and discussing it’s validity in virtually all of my presentations with some of our nation’s brightest minds in medicine. I was really hoping and praying that the “experts” in the medical community would be able to tell me that it wasn’t really true. I became obsessed with requesting anyone who would take the time, including a few people associated with the IOM, to review this study in an effort to find any possible flaws. To date, absolutely no one has been able to find any. In fact, the feedback I have received has been quite the contrary. A number of respected people in medicine have said, that in their professional opinion, they believe the annual number of deaths in our nation most likely exceeds 440,000!

As utterly shocking as these numbers are, my biggest fear now is the very “human” conditioned response to problems that appear so incredibly overwhelming, hopeless, and unfixable. It’s very common for virtually anyone to go through a stage of complete denial with respect to the real situation and problem at hand. With this thought in mind, I am genuinely hoping and praying that we as a society, as well as, the medical community, patient safety oriented organization, and fellow advocates like myself, can get past this denial stage, as quickly as possible and truly begin fixing the problems associated with “human error”, internal systems, processes, and protocols, in medicine that are leading to hundreds of thousands of lives lost every year in America. With real hope, forgiveness, compassion, and collaboration, I truly believe we can get to zero deaths from preventable medical errors during my lifetime!

Recent media reports on deaths associated with preventable medical errors:

http://www.consumerreports.org/cro/magazine/2014/05/survive-your-hospital-stay/index.htm?fb_action_ids=10204438159658317&fb_action_types=og.likes&fb_source=aggregation&fb_aggregation_id=288381481237582

http://www.forbes.com/sites/leahbinder/2013/09/23/stunning-news-on-preventable-deaths-in-hospitals/

http://www.npr.org/blogs/health/2013/09/20/224507654/how-many-die-from-medical-mistakes-in-u-s-hospitals?utm_campaign=storyshare&utm_source

http://m.healthcareitnews.com/news/deaths-by-medical-mistakes-hit-records

A great new article about the foundation and Emily’s story has been recently released on Cleveland.com and ran today, July 6, in the Sunday edition of the Cleveland Plain Dealer on Page 2! We hope this gets excellent exposure for the foundation as well as for the speaking engagement scheduled for this week at Lake Erie College on July 8th. Please spread the news, the more in attendance the better. To read the entire article click here.

A scan of the actual printed edition is also attached below. Click on the image to view a larger version…

I am very excited to have been invited as a guest speaker to The New Orleans Conference: Practices in Cardiac Surgery and Extracorporeal Technologies which gets underway today! I will be speaking about Emily’s story, helping once again to push the envelope for positive change. Check out the conference website and info on my speech by clicking here.

I was very fortunate to have recently been invited onto Mark Graban’s LeanBlog.org Podcast to tell Emily’s tragic story. Each of these interviews are vitally important because of the great opportunity to reach a new audience that may potentially include an influencer or two who can drive major change. Emily’s story speaks for itself and the work we continue to do on a daily basis is SAVING LIVES. I am honored to be able to continue the fight for a reduction of the human error component of medicine through technology and best practices. Mark’s blog is a great place to learn innovative information about what those best practices are. I can’t wait to join his podcast again in the near future. Thanks Mark for your passion and grace! And a big thank you in advance to Emily’s Army (that’s YOU my dear readers!) for sharing this interview and especially Mark’s blog, which is jam-packed with engaging material. Let’s keep pressing on toward the goal together!

Click here to listen to my interview on the LeanBlog.org Podcast

I’m very pleased to say, that the video segment from the interview I did on Huff Post Live this past November, was used on the AOL homepage in the UK towards the end of March! It’s very exciting to be getting this type of exposure for the foundation. Little by little, day by day, more people are getting the opportunity to hear Emily’s story. This can only be a good thing, as the more lives she touches, the more she will save. I truly pray each pharmacy technician and hospital worker who hears it will be motivated to utilize new systems in their hospital that will minimize the human error component of medicine. Meanwhile, our mission continues!

Here is a link to the AOL-UK Homepage featuring a screen capture of the video titled: “My Daughter Beat Cancer But Died From A Hospital Mistake”

As we had previously reported, the Emily Jerry Foundation was proud to attend the annual Health Information Management Systems Society event held in Orlando, Florida this past February. There were so many great attendees, special guests, and speakers there, the event was truly inspiring. We made incredible connections while networking with some of the most cutting edge minds in the world regarding Healthcare technology systems. It was an event that re-energized the foundation, and really sparked us to give even more effort than we already had been.



While attending this event, the Emily Jerry Foundation was honored with the Education Award in the Intelligent Hospital Pavilion, sponsored by the RFID in Healthcare Consortium. This award is given to a worthy organization that is dedicated to improving healthcare delivery through better education. We feel truly blessed to be recognized in such an esteemed manner by our peers. We continue to press on toward the goal of minimizing preventable patient deaths in our hospital systems across the US. Below are scans of the program to the event where we were presented with the award along with the actual certificate, an article that featured the Emily Jerry Foundation, as well as some other promotional materials from the evening.

Again we’d like to say Thank You to our partners for giving us this incredible honor! We fully intend on continuing to push the patient safety movement forward as much as humanly possible!

We have mentioned this article in the past, but I recently received the printed version in the mail and thought the scans would be much more powerful than the online link. As soon as I finished scanning the images I noticed I had a great testimonial in my email from someone who was moved to respond because of this very article. I’d like to share this email with you all:

Christopher,
I just read your interview in the March 2014 Pharmacy Purchasing & Products insert. It moved me to respond and share a success story from my hospital. We installed an IV Workflow system (DoseEdge™) in our pharmacy in late 2010. During dose preparation the technician must scan barcodes on the drug, diluent and fluid to ensure the ingredients are correct. They also take pictures of the amount of drug in the syringe before injecting into the bag for the pharmacist to verify.

We average 20 intercepted errors per week. I believe most of these would have been caught by the pharmacist, but…… In addition to DoseEdge there are several robotic and manual systems on the market. Perhaps in a future publication your foundation could advocate for barcode scanning in all sterile compounding.

P.S. I really like the angel label idea and plan to incorporate into my process.

Stephen L. Speth, RPh
Pharmacy Manager
Indiana University Health Bloomington Hospital
601 W. 2nd St.
Bloomington, IN 47402
812-353-5615

I get so encouraged when I read things like this. A special Thank You goes out to Stephen Speth for sending me this note. It means we are starting to win the battle for patient safety, and gives me more motivation than you can imagine to press on! Please click on the image below to download a pdf of the scanned article as it printed in the latest issue of Pharmacy Purchasing & Products Magazine.

Just wanted to follow-up on the presentation I gave at Vermont Children’s Hospital at Fletcher Allen Health Care on March 5th. The entire Pediatric Grand Rounds event went great, as evidenced by the awesome Thank-You letter I was sent by Dr. Lewis First, the Chief of Pediatrics at Vermont Children’s Hospital. I always get energized by these incredible events, especially seeing the passion that the caregivers have for making their facilities a safer place for patients. I can’t thank them enough for giving me the opportunity to come visit and share my story. See a scan of the full letter below!

We at the Emily Jerry Foundation are proud to announce a mention of our mission/organization by Mark Graban of Leanblog.org in a recent article titled “Some People Who Are Making a Difference for Patient Safety”. Leanblog is run by Mark and focuses on being “Lean in hospitals, business, and our world.” Being “Lean” refers to “The Toyota Way” management system, which has two parts: 1.) Eliminate waste and non-value-added activity (NVA) through continuous improvement, 2.) Practice respect for people. The article highlights three deserving foundations that are making an impact by trying to turn tragedy into triumph. The Louise H. Batz Patient Safety Foundation and The Josie King Foundation join the Emily Jerry Foundation on this list of patient safety advocates that are working to eliminate preventable medical errors. We are thankful for people like Mark who are attempting to shed light on organizations such as ours. I am also excited to have been asked to join Mark as a guest on one of his upcoming podcasts!

Click here to read the full article titled “Some People Who Are Making a Difference for Patient Safety” on Leanblog.org

Pharmacy Purchasing & Products magazine is the health-system pharmacist’s premier source for practical and actionable information on the products and services that impact their practice. That is why I was very excited to be asked for the opportunity to do a Q&A interview session regarding details on the Emily Jerry Foundation and especially highlighting our advocacy efforts for safe pediatric medication labeling.

Click here to read the full article titled: “Advocating for Safe Pediatric Medication Labeling” which appears in the March 2014 edition.