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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. Not many people think about this when their loved one is taken into hospital, as this is a place where they should be taken care of. So it would be in anyone’s best interest to learn more about hospital errors, just so you understand what to do if you ever found yourself or a family member in this position. 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! Medicine has been changed over many countries, marijuana is one of the reasons why the medicine has changed, some countries allow marijuana but others don’t. You can get your medical marijuana card in some countries but not in others, you should check the laws before smoking marijuana in any country, it can have a lot of amazing health benefits including both mental and physical health.

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!”

—

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. Medical practitioners might want to browse this site for solutions to validating their data more effectively and more.

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. Many want to go for Southwest Care because it is likely easier than going through that mire of paperwork. 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”. Measuring the performance of your vendors is something that many firms drop the ball on, which is why specialists in the field are offering methods in suppliers performance management in order to avoid these issues as much as possible.

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

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!

photo credit: Ontario Trial Lawyers Association blog

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. With this being said, I can see now why the use of a birth injury lawyer would be necessary, if any parent has to go through anything like we have. It can be a lot to deal with and is not something that anyone should have deal with on their own.

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. This is why it is essential to have contacts with reliable personal injury lawyers so that you can claim the compensation you deserve.

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