Going to the morgue . Becare. Danger at the doctor. Heres bill hemmer. When we visited the hospital we hope to be cured and not sicker. As a society we are well aware of the Heart Disease and cancer and so on. What if one of the biggest threats is the world of medicine itself. This hour we are looking at medical errors and how are they managed and what can we do to prevent them . And a warning that some some of the things in the report may disturb you. We begin in cleveland, ohio. I thought she was amazing. Friends called them barbie and ken. Icley and chris were college sweet hearts. First came nate and then Catherine Elizabeth and then emily. There was a problem with emily. She was born with a external tumor at the base of the tail bone. And the surgeon said chris, dont worry about this. This is benign. We can remove it. Emily bounced back from the surgery and then at 18 months. She was starting to grab her side is every once in a while and wince in pain. They took her for an mri. Chris who as it happens, worked for a medical imageing company feared the worst. All of the sudden, the radioologist and emily surgeon came out and said to sit down. Emily had a grapefruit sized mass and would need chemo therapy immediately. Why did this happen . Why is this emilys second major affliction and shes only been in the world for a year and a half. Are you having fun, emily. She got monthly treatments in cleveland. But emily did not seem to suffer from the side affect of therapy. They worried she was not responding and went for a second mri. And a miracle had occurred. We were informed not only did the tumor disappear, there was not scar tissue in her abdomen remaining. The jerry family was looking forward to their future together. We were elated. I wanted to take the kids to disney world and continue to grow as a family. To play it safe. There was one more round of chemo therapy to insure there were no cancer cells left and they agreed. Emilys second birthday she went in for her final treatment. Word had travelled throughout the whole facility and all of the clinicians had heard of this beautiful angelic little gifrl afflicted and they are bringing her cookies and birth kay cards. The treatment went well. On the third and final day, siblings nate and catherine were getting ready for the celebration of her returning. They were elated and couldt i a ratified in the hospital 15 minutes after they started the iv. That was the only time that i was late before they started the iv. And when i walked to it emilys treatment room on the second floor, i remember this in slow motion although it happened quickly. My wife was holding emily and she was unconscious. And my wife had just this horrible look of fear in her eyes and i said what is going on . She shook her head. And at that moment, it seemed like it is burned in my brain. No one could figure out why emily was unconscious. He was take tone the intensive care unit and her brain started to swell. I cant imagine the amount of pain that little emily had to be going through. For three days, emily showed no sign of brain activity and they had to make the most painful decision. They took her off life support. What was the most difficult part in all of this, my baby girl was cured of this horrible affliction and now she was taken away from us. I was thinking to myself. I was supposed to take my little girl home, and now, my little girl is going to the morgue. Our suv was parked on the top floor of the parking garage. And i thought to myself. Maybe be i should take a flying leap up of the parking garage and join my little girl. But chris realized he could not give up. He could not let his daughter die and have it end at that. He decided to investigate the cause of emilys death. This is not Rocket Science here. It had to be something with the iv mixture and i dug through the trash and found the full bag. I want to give the administrator. The pharmaceutical tech had created the mixture. And the pharmacist was busy that day and okayed it without properly checking it first. I made the assumption that a registered farm suit is going to prepare all medication and as i researched this, i found out that is not the case. Emily had been given a 24. 3 concentration, 26 times the amount required. Thats what killed his daughter. For many, many years, this is something i felt guilt about. It was one of the first times i was not there. And it was on a compounding bag and insist that the pharmacy why is this in a compounding bag. I was 15 minutes late. In the end the hospital apologized for the error and the pharmacist that signed off on the solution was fired and license revoked and tried for involuntarily manslaughter and received 600 hours of Community Service and probation and six months in jail. The jerry family received a marginal settlement from the hospital because chris refused to sign a full nondisclosure agreement. But kelli jerry disagreed with the decision and that was a last casulty, their marriage ended in divorce of june 2009. I think that is one of the things that led to the demise. What are you going to do, chris to change things. Emily is gone and nothing we can do to move on as a family. What burned in the back of my mind, how many other children are going to die due to preventible errors. I didnt feel like it was optional. Later, well show how chris jerry fought to make sure it is never happening to anyone else. When we return, well talk to a doctor who claims that the medical errors come in all shapes and sizes and dramatic as amputating the wrong limbb or mundane as reading a prescription. The problem is widespread and deadly. Medical errors collectively represent the third leading cause of death after Heart Disease and cancer. Nthird. Third. The doctor is a surgeon in baltimore. He also sees patients at sibling an affiliated hospital in washington d. C. He is author of unaccountable and a leading advocate in the fight against medical errors. The team had prepared the wrong side of the body. And we came to do the so called check list. Wait a minute. Right side. And you guys prepared the left side. It could have been a disaster. The question is, how many such mistakes are not caught in time . He believes that more transparency is part of the solution. We need to talk openly and honestly about the near misses. And talk to doctors and nurseses and family members or person out there that has had an interface with the Health Care System is. They haves story. I discovered what i want to be is a nurse. All of my jobs are geared to taking care of people. None person with a story is jany gardener. She studied to be a nurse. And she has a decades worth of experience as a nurse. Fox newses correspond antispoke to her. I saw patients medical by a medication error. Tell me what happened. You are fresh out of school and on the job and excited for your new career. I discovered the medical error. He had been given a large dose of the medication. This patient was supposed to get 90 half an hour ago. And very obviously what happened the nurse drew up 90 units of noef los. And injected the patient with it and 45 minutes later we did cpr on him. This is upsetting for you. Oh, yeah. We killed somebody s dad. According to the doctor, what nurse gardener witnessed is not unusual. The journal suggests that the number of deaths due to medical error are higher than thought. The old number of hundred thousand deaths a years outdated and underappreciated with the magnitude of the problem. 251000 in our own analysis. It wases very startling. Dr. Michael daniel is the coauthor of that report. You take a number of 250,000 on its own, you dont have a good idea what that moans and compare the number of deaths dew to cancer and Heart Disease and respiratory diseases and you realize it is it a large burden and that is scary. You stand by the number . Absolutely. If someone dies of Heart Disease. The doctor fills out a death certificate and thats how we have the health statistics. 90 percent of the diagnossis of the death statistics are guesses are assumes that the doctor who issues the dead patient did everything. And dr. Michael has worked ho high profile cases such as the assassination of jfk and dr. Martin luther king and the o. J. Simpson murder case. Death certificates do not adequately reflect. It is the statistics as to cause of death very difficult with wide margins for error. What can be done to get more accurate statistics and prevent more errors. Autopsies are a way to reveal medical errors and treatment was particularful or successful or not successful and what else could have been done. There is amount to be learned from the autopsy. Absolutely and how to prevent those mistakes. We should have more autopsies. Gerald is a doctor in louisiana and specializes in skull based surgery. Back in the 1970s, we had a 50 percent autopsy rate at hospitals. Currently it is less than five percent. For us to have a 100 percent autopsy rate in this country, all it would take one autopsy for every pathologyist and we would have it in the country. The cost and fear of punitive measures prevent doctors and hospitalses from performing the autopsies. The average price is 1000. And not wade for by health insurance. And the question is who will pay for it . So autopsies would give us more Accurate Information in your view. It helps to identify and preventible areas and reasons that people get sick and sometimes die. K the doctor questions the accrazy of the study, he admits medical errors happen and occur. I think it isax rageerated number. It does not reflect my experience with experience with all of the physicians i have spoken with. If you talk to doctors and patients, they have seen near misses and preventible harm that should not happen. Coming up, you will meet a doctor who has the experience of dealing with a horrors of mishaps from the patient get ready for the rio Olympic Games by switching to xfinity x1. Show me gymnastics. X1 lets you search by sport, watch nbcs highlights and catch every live event on your tv with nbc sports live extra. Im getting ready. Are you . X1 will change the way you experience nbcuniversals coverage of the rio Olympic Games. Call or go online today to switch to x1. When i was a young professor, my wife at the time, she was 33 years old and she sud denly got pain in her right to the. He was a star athlete in Yale University and now a professor of medicine in the university of florida, he knowses full well the repercussions of medical error after first wife mary sought help for to the pain. She sought care from a neurologist and followed by an internist and they didnt come up with the proper diagnosis. She got clots in her leg and admitted to the hospital and got insufficient blood. She had a heart attack and kidney failure and a ten percent chance of survival. Miraculous he gave her steroids and once they started, all of the symptoms were reversed and she walked out of the hospital. It was a miracle she survived. As a result of the brush with death. His career changed direction. I decided to change my career and i actually took a fellowship at hafsh beard Business School and studied errors through the business world. Businesses deal with quality. And the problem with health care was. It didnt matter the quality but you got paid. I helped to develop products and on line course to desiminate the college we need to improve health care. During the tennis game he tore his a chilles tendon. I noticed my foot turned blew when i went in the water and felt funny. I was told it was nerve damage from the surgery and i Department Think anything of it. 17 years after the tennis injury he was paddleboarding. Over the month did it not and turned white. And i lost all of the circ oulgz below my know and every other part of my body it was normal. And the surgeons were dumb followuppeded. And the only choice was to do above the knee ampitition. And i said what happened to my left leg not to the right. The only thing was the a chilles tendor surgery. I found they placed a tourniquet above my knee two and halfhours. That had damaged the arteries. And living off one instead of three vessels and it was clotted off and explained the loss of my leg. It was a surgical that caused the loss of his leg. He gained a unique nature. No one intended to hurt me. It motivated me further. And i still care for patients. I show patients what happen to me and they bond with me. So it was a terrible loss and in other way i had gains in my ability to counsel patient ands gives me more credibility in the Patient Safety world because i have been on both sides of the fence. Meet a mareap corporate that back to fox news reporting. So far, we have seen how patients can be victims of botched medical procedures. Sometimes the system can fail. We love jason and we miss him. He was always a positive funny person. We sat town with linda and marvin after a home in stephenson point, wisconsin. He had a lot of friends and always known to be the class i dont know and had a smile on his face and made you laugh. When jason turned 19, he joined the marines. He was in infantry and gave it 110 percent. And he was super proud to be in the medical. He loved it. Being very active and a good athlete. He took it to the top. After completing the fullterm as a marine. He came home and got married and had a daughter. And some point, he had an a tikz to pain killers. They suspect their sons problems may be connected with a severe head injury he suffered in hawaii. He so manied to change. Five years, jasson sought treatment to battle his addiction in va. I was surprised to see how many meds. He didnt know how to keep track of what to take. You cant imagine yourself taking meds for te pregz and anxiety and now a handful of them. And though throwing them in a cocktail. Jason wanted to get his life back on track. And voluntarily checked himself in the va hospital. He was to the point where he would take something to get him going. And that night have to take something to knock him out and he was not happy with it and his family was not happy with that. He needed help. And he trusted them. He was in physically good shape and everything before this. And after they put him on all of the meds he went to 185 to 253. He was a guy who carried people and went to a person who was strug hing with his life. Jason entered with hope that the doctors would adjust his medication and live a normal life. Instead, his condition got worse. He said i am worse off now than before i came in. He was like i cant take this anymore. And that was a tough day and i made calls to doctors and things at the time. They scheduled a meeting. And the doctor said you cause me a lot of problems here. And that was the first thing she said. You may know how to build houses and pound nails but nothing about taking care of your son. Marvin and his wife and daughter went to visit jason. He was mumbling and holding his head and when they questioned and went to the desk. They said he had a mi dpran. He will be good in an hour or two. And that was it. And they hung around a little longer and we waited for us to love. And then 4 or 5 hour ones later, hes not breathing but well take him somewhere. Helicopter will come in and well get him somewhere. And it was an hour and 15 minutes drive. They are not calling us. And we called them back and so manied like it took them a while. Just come here to the building. I said hes gone and i just know it. The morning that he died, he called me the night before. Bring my truck and i am coming home for my daughters bitter day and heave for her pirth day. And after he died. He had a present in his locker room for her. And he had everything all set to come home. So. He was a good kid. An autopsy was ordered by the hospital. We got the call from that area that was handling the autopsy and they said it is not a migraine. Jason didnt have a stroke. His heart was fine. We have no answers. He was a healthy 35yearold male and we need to do more tests and could take a while to see what he passed away from. The autopsy concluded that jason died from mixed drug toxitty and antipsychotics and tranquilizers and muscle relaxants and tramedoll. He was there a two week period. And we didnt know all of the meds from the last doctor. And we found 14. And we have to stand up and stop this problem and turn it around. Medical mistakes can happen to anyone. Even the rich and famous. Up next, hear how a standard procedure ended joan rivers life. My cousins wedding is coming soon. I like the bride more than the groom. Turquoise dresses. So excited. Did all her exes get invited . No ones got moves like uncle joe. When its go book on choicehotels. Com for instant rewards like gift cards, plus savings of up to 20 . Book direct at choicehotels. Com which saves money. Rance a smarter way, like bundling home and auto coverage, which reduces red tape, which saves money. When they save, you save. Thats home and Auto Insurance for the modern world. Esurance, an allstate company. Click or call. Esurance does insurance a smarter way. They offer a single deductible, which means you dont pay twice when Something Like this happens, which saves money. Esurance is built to save. Thats home and Auto Insurance for the modern world. Esurance, an allstate company. Click or call. Announcer in your new role, we helyolp. [airplane sounds] visit aarp. Org caregiving for information on how to provide even better care for the person who once took care of you. Red roses too i see them bloom for me and you and i think to myself what a Wonderful World music i hear babies cry i watch them grow theyll learn much more than ill ever know and i think to myself what a Wonderful World music oh yeah weve seen the damage that medical mistakes can do. The truth is medical disasters can happen to anyone, even the rich and famous. You look at the amount of people you you employ and if i am out of work, this whole thing is out of work. This is a beautiful neighborhood in manhattan that happened to be the epicenter of health care in the world. It is called pedpan alley. This is the facility. That is the last street she walked on. And fox news legal analyst Peter Johnson junior had plenty of experience suing and defending doctors in hospital. We asked him about the public records on joan rivers death. There is so many in a 20 mile radius. She came here because her throat was sore and came for an camera down her throat in her digestive system. But what happened she wound up getting three procedures, two she never consented to. And the night before her appointment in august. Joan called daughter melissa. She went for a routine procedure that hundreds of thousands of peep go for nothing to do with money or shbt or status. She she was supposed to get sedation. And there was a question of how much she got and procedures received. It shut down her airway. My phone rang early in the morning and who is calling this efrl and i pick up the phone and you know, your mom is not breathing. And you are just absolute cold. Melissa was told that her mother was taken to the hospital and put on life support. Seven day it is after walking in the Outpatient Clinic she was pronounced dead. Once all of the noise surrounding the funeral. You go wait a minute, why, why . Melissa rivers filed a lawsuit against the endosskopy and the associated doctors with with the clinic. She came here for a simple procedure. Who was in the room with her that day. Five different doctors, not all of them authorized to be there. A ghaster enterologist and an emt. And or nose and throat doctor. How was it possible a doctor not authorized could be there. It shouldnt have been authorized or allowed. The complaint was hard to read. It was like a medical nightmare. Doctors incles dr. Coen. And the medical director. And he took out a cell phone and took photoss of joan river while under sedation. You cant legislate good judgment or morality. You cant. And dr. Korovin had no right to perform the endoskopy and the anesthesiologist who failed to demand a crash card be put in the room. It would have made a difference for my mom. Patient facilities, do they have the same rules and regulations and standards as a regular hospital. They dont really. It is murky as to what standards they have. An investigation revealed substantial violations, including that the dr. Korovin had no surgical privileges. The doctors did not contest. Thats as close as i will get to accepting responsibility for their behavior. The financial settlement is sealed and believed to be be in the tens of millions of dollars. Dr. Kohein stepped down but they are still licensed to practice in new york state. And further investigation is underway. They are doing an investigation and well see what comes with that. I have my personal hopes of how that panned out. I want to stop for a second and make sure everyone is not only ill walking the clinic, but alive coming out of the clinic. Coming up next, how to take charge of your treatment as as weve seen, medical errors can be a devastating problem. There are people who are trying to make things better. There are more places for errors, because there are more medications being given than ever in the history of medicine. Part of the solution is to have patients themselves take charge of their treatment. Were going to do a procedure, and ill explain it to you, what it is. Dr. Manny alvarez, chairman of obstetrics and gynecology at Hackensack University medical center, has a checklist for being your own advocate. Number one, bring somebody with you, to listen, to ask questions, to write things down. If they give you your medication, ask questions, what is that medication . If theyre taking out your balla blood, you can ask, why is my blood being taken. Make sure the staff follows all hygienic protocols. Can hand washing in a hospital make a difference in transmitting bugs . The answer is 100 yes. Is hand washing something thats routinely done by Health Officials in a hospital . No. Only 30 of people wash their hands. If you think you need a second opinion, seek one out. Good. You okay . Make sure that you participate in every activity when it comes to patient identification or making sure that if youre having surgery, the surgeon has the proper knowledge. The patients name is jane smith. Smith. And consent for the type of operation that youre going to have. Everybody in agreement . Agree. When in doubt, call it out. Meanwhile, there are Many Health Care professionals dealing with the matter of medical error. Help, help, help, help call a code blue we traveled to scottsdale, arizona, to the 18th annual national Patient Safety congress. We have gotten better, but its been too slow. And Everyone Wants these changes to come faster. Dr. Southwick, with whom we met earlier, was one of the many attendees. So what we do is share our experiences, our best practices, and our expertise with each other, so that we can all become smarter and we can all apply what is working in other areas of the country. Were teaching Patient Safety in medical schools and Nursing Schools and other forums to make sure people understand what are the causes of error, how do you Design Systems to try to prevent error, et cetera. Reporter dr. Tajil gandhi is an associate professor of medicine at harvard medical school. We still have a long way to go, but we have made progress. Teaching Patient Safety is one thing, but dr. Gandhi feels in order to create safer hospitals, the medical culture must also change. Were working on creating a culture of safety where everybody is comfortable, speaking up, and know that they wont be blamed or punished for speaking up, but actually will be listened to. You know, you want your nurse to speak up when they see something that doesnt look right. And its our job as surgeons to empower them to say, look, if you see something that doesnt look right, say something. Im capable of making mistakes. The families youve heard from tonight are also determined to change things. After the death of marine jason simcupski, a Senate Investigation showed systemic failures in the v. A. Facility that treated him. And the fallout included the firing of the hospitals chief of staff, dr. David houlihan. Studies have shown that soldiers and veterans use opioid painkillers far more frequently than civilians because their military training and combat lead to far more injuries. The bipartisan david simcupski act passed in the house of representatives. The bill is passed and without objection, the motion to reconsider is laid on the table. Lawmakers expect it to pass in the senate soon. Theres guidelines to protect the veterans and service men and women on opiates, on making doctors more accountable for their wrongdoing. We dont want other vets to have to go through this. Melissa rivers is determined to pass a joans law. I can now move forward to try to make a change and try and create some sort of legislation in which, you know, in the best of all possible words, will be called joans law, and be able to lobby for stricter regulation and more oversight to these different clinics. Hello, everyone. Welcome to surviving health care today. After chris jerrys 2yearold daughter, emily, died, jerry beganed to advocat for a law in ohio, allowing pharmaceutical technicians to require proper training and certification. Emilys law was passed in 2009. Chris then started the emily jerry foundation. You can go on the website and see which states satisfy their pharmaceutical technicians. Ive always believed this. One life lost to preventable medical error is too many. And because preventable medical errors are just that, theyre preventable, means logically, they should have never have happened. We dont want to create fear. We dont want to create hysteria. We want people to recognize that its a great profession, with doctors trying to do the right thing, but its a messy system. And unless you take charge of your own care, it could be a very scary proposition. Hospitals are among the most trusted institutions in our country, but health care is as much art as it is science. And mistakes, as you have just seen, do happen. But there is good news. The Health Care Industry has recognized that medical errors are a problem and its trying to find ways to reduce them, as much as humanly possible. Thats our thank you is what we say. But we mean so much more. We mean how can we help . We mean what can we do . We mean its our turn. To do our part. To serve you, for all youve done to serve us. 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