Podcast #207 – Chris Jerry, The Emily Jerry Foundation, on Preventing Systemic Medical Errors (Part 2)

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Episode #207 is part two of my conversation with Chris Jerry, founder of The Emily Jerry Foundation.  The foundation was created in the aftermath of the tragic death of his daughter, Emily – a preventable medical error caused by a number of factors and bad systems. You can read Emily's story here.


In the first part (Episode #203), Chris told the story of what happened. In part two, we talk about topics including:

  • A systems view vs. blaming an individual
  • Chris skipping over the “anger” phase of grief
  • Why his barber required more certification than a pharmacy tech compounding medications?
  • Emily's Law” was passed in 2009 in Ohio and he's working on this nationally
  • How he learned his ex-wife pursued the criminal charges against Cropp
  • Publicly forgiving Cropp and meeting him face to face for the first time
  • How we're all fallible and capable of making a mistake
  • All of the elements of the system have to fit together and work together
  • Differences between advances in automotive safety over time and healthcare safety
  • Warning people without demonizing the individuals
  • The importance of patient and family involvement
  • How to reduce hospital acquired infections – hand washing!
  • How much progress is being made in the patient safety battle?
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Emily Jerry

For a link to this episode, refer people to  www.leanblog.org/207.

For earlier episodes of my podcast, visit the main Podcast page, which includes information on how to subscribe via RSS or via Apple Podcasts.  You can also listen via Stitcher.

Chris Jerry and Eric Cropp together:

Transcript:

Mark: I think a key of this systemic view is to look and say, well, would a different pharmacist not named Eric Cropp, who by luck of the draw would have happened to have been working that day, also seen that bag? Also signed off? Also ended up in the same situation? Probably, right? He didn't have super-human abilities to look at that bag and see the concentration of saline.

Chris Jerry: Precisely.

Mark: That's just not possible.

Chris: Precisely. I do agree completely, Mark, because I've applied those scenarios as well in my mind. I really do believe that even if you were able to gather up 6, 10 of the leading rock star pharmacists at that given point around the nation.

Put any one of those in that same environment that day, and they would've made the same decision [inaudible 02:52] that bag.

I was given the opportunity, Mark. A few years after Emily had passed, I'd been going through a horrible divorce, I know that they all are, but my former wife and I were separated.

I wanted to persevere with respect to my patient safety advocacy efforts and with the establishment of the Emily Jerry Foundation.

As I'm doing this work to establish the foundation and just try to gather as much knowledge as I could about patient safety and preventing these types of horrible tragedies like what occurred with my daughter from happening to anyone else.

I was going through a horrible stage of the grieving process even though I think it was also miraculous, Mark. I say this all the time.

A lot of people who ask me, “Chris, when you were standing on that parking garage, weren't you just mad as hell at the caregivers? Weren't you mad as hell at the facility where it happened?”

The honest answer to that is “No.” I was emotionally traumatized, I always will be, I continue to be as would anybody. Like I said, it truly is a miracle that I skipped over what I think is like the second phase of the natural five steps of grieving, which is anger.

I think the reason I wasn't angry was because of the way that the caregivers had taken wonderful care of my daughter and because effectively what gets lost in this tragic story with Emily quite often is the fact that modern day medicine cured my little girl of a grapefruit-sized mass in her abdomen.

Cured her, none of us can forget that, and that's why I still, to this day, have the utmost respect for modern day medicine.

Today is because we are now curing various forms of cancer and different diseases that just 10 years ago would've been terminal, would have been an immediate death sentence.

Mark: Right.

Chris: We now have documented cases of people overcoming even stage IV cancer of different types.

Mark: Yeah, a good friend of mine is in that camp and is a patient advocate for different issues.

You're right, there are amazing things that happen and at the same time. Just purely just preventable headshaking, anger inducing, sadness inducing errors that are occurring each and every day multiple times a day.

It's not meant at all to diminish the first victim, your loss, Emily's life being stolen from her, and her being stolen from you and the rest of your family. To think about what's fair for those who were “involved in the incident.”

That might just sound like, “passive phrase, passive voice,” but it's probably more accurate than saying the person who screwed up, the person who's involved in that error, what's fair for them, an error crop, I don't know how much you want to talk about the trial or the aftermath, but what happened with Eric.

Chris: My point there, Mark, and multiple things come to mind, but the biggest thing is what was most important to me was I knew I couldn't bring my little girl back, however, I still feel and I am very outspoken about it, but I still believe that little Emily is still with me.

She's not just my guardian angel, she's everyone else's. My point is in expounding on everything I just aforementioned was the fact that I knew right from that point the day we took Emily off the life support that I wanted to be engaged in being a part of the solution to preventing it from happening to others.

Immediately after root cause analysis, Mark, I began researching and doing my homework about what did you need to do to become a pharmacy technician in the state of Ohio.

At that time, the only requirement in 2006 to become a pharmacy technician and start routinely compounding IV medications, which by the way most of our public is not aware that in all of our nation's medical facilities, pharmacy technicians compound virtually all, and those words are not sensationalized at all.

You ask any pharmacist that's been in clinical pharmacy, who compounds virtually all IV medications like they will tell you a pharmacy technician. The only requirement to become a pharmacy technician, in 2006 in Ohio, was that you had your GED.

The barber cutting my hair in 2006 had to have their cosmetology license displayed next to the barber chair. And show before they could legally cut my hair that they had 6 to 12 months, I forgot what it is, of full-blown cosmetology school and that they passed all their tests before they could legally cut my hair.

Yet somebody that's compounding IV meds going into my children's circulatory systems directly, they just had to have their GED.

Mark: Right. We've all had bad haircuts, it grows back.

Chris: Exactly [laughs] .

Mark: Yeah.

Chris: Many times we, as citizens and as patients, we don't understand these underlying issues. Many of Emily's specialists at her facility were not aware.

Some of them had been there for 20 or 30 years as practicing physicians, probably writing scripts for, I imagine thousands of IV meds for their patients. They had no idea that pharmacy technicians compound virtually all IV meds.

I'm proud to say I was able to help get Emily's Law passed in January of 2009 for the state of Ohio. I've continued on, on a national basis, because it varies on a state-by-state basis.

I have carried on this work with the Emily Jerry Foundation's Pharmacy Technician Initiative and Scorecard as well.

I know I'm skipping around here a little bit, Mark, but going back to what had happened with Eric Cropp, my former wife and I had been separated, and all of a sudden I started getting calls from the news media requesting interviews with me. I said “What's this about?”

They immediately said, “Well, weren't you aware that your former wife is pursuing a criminal conviction against the pharmacist that was involved in your daughter's death?”

I said, “No, I wasn't aware of this.”

At that point in my life, Mark, even though I had skipped over that angry phase of the grieving process, part of my grieving process which it varies for every individual.

I used to be more embarrassed about it than I am now, but definitely for a few years, I was going through what I refer to as my Lindsay Lohan/Big Lebowski days, living life a little too wild and not really caring too much, but I was establishing this foundation.

As I'm working through all these things, my response to the news media requesting the interviews was to decline them.

Mark: Yeah.

Chris: That's something that I've apologized actually to Eric for. I think it's important for our listeners to hear this because we all think about things. How would I've done things differently during that time?

I would've done a lot of things differently, but one of the key ones that I regret and was very apologetic to Eric for was that I would've been there by his side during the court proceedings helping to defend him.

I watched it unfold instead in the news media, and I see this guy being vilified for what had happened in my daughter's death. My solution was to just bow out of the media spotlight, decline the interviews.

As I learn more and I'm following his case, he was convicted of involuntary manslaughter, but the initial charges were he was being brought up on reckless homicide, all these horrible things.

He did receive a criminal conviction and was sent to jail for what had happened with Emily. He was sentenced to six months in county jail, and then six months of house arrest.

He had his license to practice pharmacy permanently revoked.

Right before he was released from jail, I had told my colleagues and the people that I work with in the patient safety communities, started telling them when I was speaking with them one-on-one, Mark. That I would really like the opportunity to be able to come out and publicly forgive Eric for what happened to my daughter to set the record straight.

We, as a society, when these horrible things happen and we determine they are not due to the reckless practice of medicine that we learn from them and we modify the systems.

Because I don't believe if you have any deep-seated anger, resentment, and animosity I think those are things that are negative to the human condition. I think it causes us to deteriorate from the inside out. It's partially for my healing process as well.

Eric and I were given that opportunity in May of 2011 for a Discovery Channel patient safety segment called “Surfing the Healthcare Tsunami.” You can watch that on the Emily Jerry Foundation's website, that clip.

Mark: I'll make sure we link to that on the page.

Chris: That was a very pivotal moment. Eric and I were brought together for the very first time since Emily's death.

We were able to look one another in the eye. I felt like I'd done my job because I was able to set that record straight, Mark, and get people, get society, when these tragic events occur and root cause analysis determines it is not due to a result of reckless practice of medicine.

We can all learn from them and modify those systems instead of just going out and lynching an individual for them and letting the systems go.

Because then, when that happens, when people like Eric go to jail and nobody speaks out then I think that it's natural again, part of human nature, for maybe the upper-level C-suits people, our nation's medical facilities, and the people that are responsible as administrators for signing checks for vital pieces of patient safety, technology, and equipment that needs to be implemented.

They probably think to themselves Mark when they get a purchase request for a half a million dollars, let's say, for an automatic IV compounder that's going to make their facility safer.

I think that these administrators might think to themselves, “Well, Jeez. Times are kind of hard right now economically, maybe we can put off this $500,000 expenditure until next year or until next season.”

Because, in the back of their minds, they think to themselves, “Well, we have the culprit that's responsible for this horrible tragedy that occurred, and they are rotting in jail anyway so why do we need to spend the extra money?”

Mark: It's easier to say, “Here's what the cost of that technology would be, then it is the cost of not having it.” Well, the risk is someone will make a mistake, “Well, we have careful people. We'll tell them to not make mistakes,” but that's ignoring human factors and human fallibility.

Chris: Yes. Mark, to speak to what you're saying right now, the fact that we're all fallible; we're all capable of making a mistake. Let's just take a hypothetical here, Mark. Let's just take a hypothetical here, Mark. Even if you were a rock star cardiac surgeon.

You graduate top of your class from Harvard Medical School. You've been practicing for 10, 15 years without any significant error that you're aware of reaching the patient. You've been responsible for saving countless lives through stellar procedures.

The fact of the matter is God made us all fallible. We're all capable of making a very human error. Having an oversight. There's only so much any human mind can endure.

Statistically, chances are pretty good that you being his hypothetical rock star cardiac surgeon, chances are you're still, no matter how many lives you save, chances are during the course of your career pure statistics and objective analysis is probably going to say that you're going to have a significant error that reaches and/or proves to be lethal to a patient of yours.

Your work is much like mine in that respect, Mark. I'm trying to get everyone to rally behind those basic core of thoughts.

Mark: Right. Tell us through the Emily Jerry Foundation, you're doing a lot of work to raise awareness and to rally people behind these issues. You might even say the right way to try to improve patient safety and healthcare quality.

What are some of the main things that you're communicating and advocating for to help solve this?

Chris: I'm advocating for, I think you hit the nail on the head, Mark, primarily for changes in attitudes and opinions across the nation. Changing the underlying culture of medicine, the negative aspects.

I often tell people, “If I were allowed, for me as a guy and as an individual, to have any job I wanted in the world, because I've always loved, ever since I was a little boy, I've loved sports cars. It would be to own a sports car manufacturing concern.

“A sports car manufacturing concern that produces state-of-the-art, high technology sports cars that are capable of driving at a very, very high speed, and keeping the occupants safe in that vehicle, while they're driving at that very high speed.”

Now, if I were the owner of this hypothetical concern, I certainly wouldn't allow my design engineers, nor do I think you would either, Mark, to allow your design engineers to put cheap tires on that vehicle that would compromise those occupant safety, correct? We probably would not even allow them to put mediocre tires on a car like that, right?

I kind of view modern day medicine on a global basis, and especially here in the United States, in that same way. I believe that we have the high performance sports car built today. We have that today.

Now, what we need to focus on as a society and as the medical community, trying to get around this huge issue of preventable medical errors and loss of life, what we need to focus on is the tires.

I know that's a little bit of a corny analogy, but I think it's a good one that kind of drives the points home pretty well.

Mark: It's not enough to just have a great engine and beautiful design, and a great paint job, and comfortable seats, and all the safety gear inside. All of these elements of the system have to fit together.

I think of the analogies to the auto industry. I mean, gosh! You see what's in the news, where there was allegations thrown at Toyota. More recent recalls and congressional hearings with General Motors. Design problems with small cars, and ignition switches.

The range, the number of deaths, again not to diminish any one of these accidents of course, 13 to 40 deaths. These are all out in public. There are police reports.

It's a problem that really a company could move slowly and drag its feet in responding. The government regulators might be slow. Ultimately, these problems occur out in the open. Problems in hospitals, where it's not 14 to 40. It's 140,000 to 400,000, depending on which estimate. It's private. It's one-at-a-time.

I think that's one of the things that gets in the way of improvement is this lack of public understanding, this lack of awareness, this lack of pressure.

There certainly aren't these congressional hearings all the time, hauling healthcare CEO's in to explain why so many people are being killed by preventable errors. It just doesn't happen.

Chris: Right. I think the significant points there are increasing public awareness of all of these things. I didn't discover them until after the fact really. I really wasn't aware of these things.

Now, that I'm submersed in it though, I even see it to speak to what you're saying, Mark, on the other side of things, if we're talking about using analogies from the auto industry especially. I think modern day medicine can be compared to the auto industry in let's say the early '70's, the late '60's.

I'll tell you why. During the early '70's, even though I'm an old guy, and I'm going to be dating myself now, Mark, but that's OK. I'll never forget. My mother had what I thought as a little boy, I thought it was the coolest mom car out there. She had one of these old Corvair. I don't know if you're familiar with that car?

Mark: Yeah. I've heard of it. Was this the Ralph Nader car, made famous by?

Chris: This is kind of one of them. I always thought this was a cool car. It's ironic that you just brought up Ralph's name, because I'm about to.

Mark: OK, sorry. [laughs]

Chris: No. Don't apologize at all. This just tells me that you and I are on the same wave length.

I always thought to myself, “Boy! My mom has got the coolest car! I'm so proud.” She's dropping me off at Little League Baseball, and all the other boys are looking at this cool red Corvair that I'm getting dropped off in.

I always wondered as much as I loved that car, Mark, even as a little boy. I wondered to myself, “Why aren't there any seatbelts like there are in daddy's car?” I thought about this the whole time.

Lo and behold! Now that I've been submersed in patient safety now, I'm drawing analogies back to those times. We hear about people like Ralph Nader, who in the early '70's was a big proponent of safety with respect to automobiles.

How many lives would be saved if the car manufacturers took existing technology that they already had designed in terms of seatbelts, and what have you? In fact, I'll expound on the “what have you.”

I've even heard rumors, Mark, and maybe you can share with me if this is true or not. That there were a few car manufacturers that had actually designed working airbag prototypes that worked in the early to mid '70's, at that time.

My point is this technology existed, and had been designed at least for seatbelts. As I understand history, the car manufacturers were reluctant to put the seatbelts in there.

They were fearful that if word got out that just driving a car was an unsafe proposition, that fewer people would purchase their vehicles if they thought that, “Hey. We promote this fact, and we're going to be showing that our products are dangerous,” and what have you.

Mark: I could probably imagine that was the case. I don't know the details on the history of development of airbags. I do remember being exposed even in the mid '90's. Well, early '93, doing a summer engineering internship with a major auto maker. We were looking at different types of glass for vehicles.

Generally, automotive glass is engineered to be pretty safe, compared to your average pane of glass, in terms of not having big shards that are going to cut you. It was pretty well engineered as far as glass goes. They were looking at further advances that would have been incrementally safer.

I know there were discussions of, “Well, if we put that product in our luxury cars, the more expensive ones where we can absorb that cost. We're not putting it in all the vehicles. Oh, my gosh! That opens us up to liability.”

I can imagine there was discussions like that if the technology wasn't perfect, or if they didn't put it in everywhere. Even like you said, creating a perception that driving a vehicle at 55 miles an hour has its safety risks, which I think, “My gosh! We all would recognize that.”

I guess, I can appreciate some of that reticence to be forthcoming about trying new things.

Chris: I think analogies can be drawn between the automotive industry and to modern day medicine right now. I think there's a lot of good analogies that can be drawn from that.

Here, we have the manufacturers in the early to mid '70's being nervous or reluctant to truly open up, and I guess for lack of a better word, be truly transparent with the general public about what an inherently dangerous prospect it really was for all of us to drive to the grocery store a couple miles away. It was a pretty dangerous proposition at that time.

Bottom line is we had the solutions. Those being at least the seatbelts. Now, here modern day, flash forward, and we find that in the marketing.

I think I just saw, I think it was a Subaru commercial, where they're showing the remnants of this car on the back of a flatbed that has just been totally mutilated. You're wondering to yourself as the viewer, you're thinking to yourself, “What could have happened to those occupants?”

Here, they're boasting about their safety features in I believe the Subaru, saying, “Hey! We're one of the safest vehicles. We've put so much money and time into designing these things associated with our airbags, our seatbelts,” all of their automated safety equipment.

Now, they're conveying that message. They're being honest and forthright with people. People are now finding that's a reason they want to buy those Subaru vehicles.

Mark: You look at the National Highway Traffic Safety Board Administration. I'm getting the different acronyms. Mid-afternoon, I need a cup of coffee.

You've got these different federal regulatory groups. There's somewhat standardized and federally regulated safety standards and crash tests and reports that are done, not just by the federal government, but by Consumer Reports and other independent groups.

Healthcare, you've got some groups like Leapfrog Group and others that try to do patient safety grades and score cards. There's really not a similar federal effort that we would have for aviation safety or other types of transportation safety.

I've seen articles where Lucian Leape, one of the fathers of the patient safety movement, is advocating for something that would be similar to an FAA for healthcare.

We can point to examples, not just Lean manufacturing, but we can point to other industries, other known best practices that take into account human factors, human nature and dynamics that have led to such dramatic increases in, say, aviation safety. Not to mention auto safety. There's a lot of things out there.

I think we know what to do, but there's not the public or political or even management support within a lot of organizations to honestly admit, first off, “Here's the problem. Here's the scale of it.”

I think it's pretty rare. I've run across a few hospital CEOs that will talk bluntly to their employees about, “How many patients do we plan on harming this week?”

Obviously, they're not wanting to, but to talk about, “If we're not improving processes, statistics would show we are going to harm people this week through medication errors and other types of preventable problems.”

People would say in the Toyota circles, first you've got to define the problem, or if you're trying to say, “We don't have any problems,” as the saying goes, no problems is a problem.

Chris: Those are words of wisdom, Mark. Without a doubt. Without a doubt, because that's the whole point that I'm trying to get to, is the fact that if we continue, historically, when tragedies like what happened with my daughter Emily happen…

If that would have happened 20 years ago, it probably would have been brushed under the rug and forgotten, because it's an embarrassment to the institution where it happens. It's human nature to try and compartmentalize things that are horribly traumatic and upsetting for us, emotionally, on everybody involved.

Mark: I would have been worried about that occurring eight years ago or even today, like you said. Things being covered up or not being looked at.

Chris: Brushed under the rug. Then, what happens — again, another form of human nature — is the fact that we all try to, when we face a horrific problem or situation that needs a solution, isn't it human nature? At least for a nanosecond or two, Mark, to try to minimize that problem at hand? Say, “Oh, this isn't that big of a deal.”

Mark: Or to say, “Well, we'll blame somebody and punish them and problem solved.” I think that's where I think part of the discussion with the public needs to not just — and certainly not to be alarmist — but to say, “Look, there are risks of going to the hospital for even the most routine procedure.”

To be aware of those risks, but at the same time, being really careful, like you did at the very beginning of our discussion here, not demonizing the individuals and saying, “Well, don't go to the hospital because some idiot nurse or stupid doctor's going to hurt you.” No, that's not it at all.

Chris: Precisely.

Mark: It's about being aware of systems. I know you've met Laura Townsend from the Louise Batz Patient Safety Foundation. They have an excellent guidebook that I share with anyone I know that is going to be going in for a surgical procedure. I know people have found the guidebook incredibly helpful, because it points out, “Here are the questions you need to ask.”

It does so in a very, I think, matter-of-fact, non-alarmist way. Otherwise, people are going to discover these things on their own.

It's better to have a little bit of advanced warning of knowing what you need to keep track of and questions you need to ask. In an ideal world, it wouldn't have to be that way, but if it was you or me or my family, I would certainly be looking out for them.

My wife and I have this deal. We check in on this every once in a while. “If I'm hospitalized, I need you or someone to be there with me, and vice versa.”

Not to be obnoxious to anybody, or not to be disrespectful, but just to be monitoring and overseeing things, even though you're not a medical expert. Which puts patients and families in a bad position.

I think being aware and having at least some key questions can really help put luck on your side a bit.

Chris: To understand what the core issues are at hand, before going in for treatment, and then subsequently, and this is where I really try and guide people in the general public that are, I guess, not working but concerned about their care or their loved ones' care. That is, I always try to stress to them the importance of patient and family engagement in your healthcare.

We all need to be involved. You do need to be knowledgeable about things like hospital-acquired infections. I think there are many people that don't even understand. They're very fearful of hospital-acquired infections, because we hear about how the news media sensationalizes things, any chance they get.

They're very fearful of going in for a procedure because they hear about how many people are dying from hospital-acquired infections, but many people are not cognizant of the fact that one of the biggest ways in healthcare that we can reduce hospital-acquired infections, believe it or not, and it's true.

This is objective fact, and not my opinion. I know you'll support me on this, Mark, is through CDC hand-washing methods in the medical facilities.

Many people in the public aren't aware that when they have multiple specialists coming in to see them, during the course of their stay, for any procedure, you have three, four, five different types of physicians coming in to see you and treat you.

You see one of them walk in and not wash their hands. You're well within your rights as a patient to — very politely and tactfully, though — say to that physician or that nurse, “If you're going to give me an examination, please wash your hands for me.”

People are afraid to speak up. They're not going to know to speak up unless they know that that's where the root of the problem is, I guess.

Mark: Start to wrap up here. There's so much we could talk about, and I encourage listeners, if you've got questions or other things you would want Chris to explore here, I think we had an agreement up-front that we could maybe do another discussion.

Chris: Yes.

Mark: As we start to wrap up, one question I wanted to ask was whether you feel like there's progress being made. In the time that you've been involved in this movement and with the foundation, how much progress do you feel like is being made right now?

Chris: I feel, even though the numbers, the sheer numbers, Mark, which I've got that side of my brain which is more analytical about these things. I look at the numbers being so astounding, at over 440,000 lives a year.

To answer that question directly, I do feel that there are some incredible changes happening. I do.

Much of my work is spent, as you know, Mark, going and speaking at different medical facilities around the nation, and spending time with them and their quality teams. Their upper-level C-suite people, their boards of trustees, all of their caregivers. I'm seeing these changes in attitudes and opinions are most prevalent.

I'm seeing those changes occur in the way that they're viewing these things as they relate to our whole interview we've had today. All of those topics we covered today, and I know we covered a lot of them, I am seeing the upper-level. I'm sure you are, too. I don't mean to put words in your mouth, by any means.

I'm sure you'll agree that many of the presidents and CEOs that you and I speak with, especially on a one-on-one basis, I think they're starting to show a change in how they understand and perceive the vital issue of preventable medical errors.

I think when I first started, I think many of them used to think, “Chris, this horrible story of Emily and what happened to her could never…”

They think to themselves, “This could never happen at our facility. We're top-notch.” Now, today, if I take a snapshot from today, Mark.

I believe that many of them are coming to the realization that what's changed now is that they realize that, “Hey, chances are that a horrible, awful, unimaginable tragedy like what happened with Emily could and may very likely happen at our facility, so we need to implement the safeguards.

“We need to modify our internal systems and processes and protocols so that these things don't happen. We need to be proactive about it, rather than just ignoring it.”

Mark: I think there has been some change in thinking. There are some organizations that are, I think, absolutely top-notch, and I give credit to their leaders for really embracing this problem and not just wishing it away. I think it's not happening as broadly enough as the impatient side of me would want.

Chris: You and I share that, Mark. I'm one of those people that feel like, if I build a logical argument for just about anything, a very objective argument for something, where I'm able to provide facts and things like that — and I know you're similar in that respect, Mark — then, I feel to myself that I should be able to snap my fingers and that should be able to happen.

What I have learned through doing this difficult work, sometimes, is that the change doesn't ever happen as quickly as we want. You and I want it to happen overnight, Mark.

Mark: The change and the improvement in the level of safety and quality can happen quite quickly in hospitals. Part of my impatience comes from seeing that it's been demonstrated, and it might take 20 years or a generation to change an industry. It doesn't take 20 years to dramatically reduce risk and harm in a particular hospital.

The encouraging side is that if more hospital leaders get to it. We can see great things happening. Whether they're a small community hospital, or like you said, any large hospital.

I don't mean to single them out, but if you look at the Josie King story and her death and Sorrel King of course is doing great work to try to help improve patient safety. That occurred at Johns Hopkins.

To their credit, they have also been working with her. Others within Johns Hopkins have done great work to demonstrate and promote patient safety and healthcare quality. That's about as top-notch, world-renowned as it gets.

Like you said, it's not lack of training. It's not lack of people from the right medical schools. It's not a lack of technology. These are, I think, culture problems, systems problems, management problems. That makes it more fixable.

Chris: Correct. Again, Mark, that's what keeps me going on a daily basis and getting out of bed early in the morning, going down late at night, and being so passionate about this work.

Is the amount of hope that I have. I'm seeing those changes, much like you are, with organizations like Johns Hopkins taking a leadership position, by looking at things a little bit differently.

By leadership position, I mean addressing the problems at hand. Acknowledging the fact. Stepping up to the plate, much like Johns Hopkins did. The facility where I lost my beautiful daughter, here in Cleveland, Ohio.

They stepped up to the plate, and I believe should be commended for taking a very bold action when they asked me to come and be a keynote during National Patient Safety Awareness Week and then to give three or four very high-profile talks for continuing medical education credits to their people. Inviting me and then promoting it very publicly.

This horrible, horrific, unimaginable incident with my daughter, Emily, occurred at their facility. At least they're taking that first step, and they've taken multiple steps afterwards. Maybe that's something for another show, Mark.

They've taken multiple steps over these past years since Emily passed away to modify their systems and processes.

For them to take that leadership position and actually invite the father of a beautiful little girl that was lost due a tragic, preventable medical error at their facility, I think that was huge.

Much the same way that Johns Hopkins invited our friend Sorrel King, Josie's mother, into their facility, shortly after it happened.

They're saying to everybody, “Yes, this horrible thing happened in our facility, but here, public and future patients of ours, look what we've done to learn from what had happened. Look what we've done to modify things and ensure that patient safety is our number one focus and the best possible outcomes are our number one focus.”

Mark: I'm glad that that's your focus and that you're dedicating so much time and energy and rallying others behind this incredibly important mission.

As we wrap here, again, I want to thank you for sharing your story. How people can reach you, the foundation's website? What do you recommend for people to be able to get in touch?

Chris: Definitely, I would encourage everyone to visit our website, which is www.emilyjerryfoundation.org, and I would also encourage any of our listeners to please feel free to contact me with any of these issues that you might have first and foremost in your mind. My email address is chris@emilyjerryfoundation.org.

Finally, anyone can feel free to contact me, even directly, at area code 440-289-8662. I would be very, very happy to speak with you and work with you.

If you're involved with healthcare and what have you, and feel that Emily's story and the programming of the Emily Jerry Foundation is in line with your efforts, there at your facility.

I'd be very interested in not only working with your facility in the important area of patient safety, but also coming and speaking, possibly, to your caregivers and to your staff, to help inspire them to continue with their efforts.

Mark: I hope listeners who are in the position to be able to consider that, I hope people will do that. Either tell their hospital administrators or professional organizations that they're a part of to have you come and dialog with them and be a part of the discussion.

There's so many people out there, working really hard. Their hearts are in the right places. I think we can equip them.

You're equipping them with what they need to really protect patients. I want to thank you for that, Chris. Thank you for being a guest here on the podcast.

Chris: Thank you very much for having me, Mark. I really appreciate the opportunity and also the continued support you've given.

Mark: I'm very happy to. Thanks a lot.

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Mark Graban
Mark Graban is an internationally-recognized consultant, author, and professional speaker, and podcaster with experience in healthcare, manufacturing, and startups. Mark's new book is The Mistakes That Make Us: Cultivating a Culture of Learning and Innovation. He is also the author of Measures of Success: React Less, Lead Better, Improve More, the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, and the anthology Practicing Lean. Mark is also a Senior Advisor to the technology company KaiNexus.

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