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Voices for Safer Care

Insights from the Armstrong Institute

Voices for Safer Care Home Organizational and Cultural Change After Surviving a Medical Error, Mike Armstrong Vowed ‘Never Again’

After Surviving a Medical Error, Mike Armstrong Vowed ‘Never Again’

C. Michael Armstrong has long been more than the namesake of the Armstrong Institute for Patient Safety and Quality. His commitment goes beyond making generous gifts to create the institute and, later, our Center for Diagnostic Excellence, or endowing a professorship in patient safety.

Indeed, he's been part of the patient safety movement for years, prodding us to do better and not to rest on our reputation. As a longtime trustee of Johns Hopkins Medicine and the Johns Hopkins Health System — including several years as chairman of the board — he made patient safety, not financial performance, the first item on the board's meeting agendas. He carefully reviewed our safety performance data and challenged us to do better in areas such as hand-hygiene compliance and bloodstream infections. Mr. Armstrong has been a driving force behind Johns Hopkins Medicine's National Leader Strategy, a health system-wide effort to be among the top performers on publicly reported quality measures. That campaign has resulted in multiple awards for our hospitals from The Joint Commission and the Delmarva Foundation for Medical Care.

What's driving him? A very personal experience with medical errors more than 25 years ago that nearly cost him his life. He was kind enough to share it in this video. We hope you'll watch and draw inspiration from it. He is clearly an inspiration to me and to our clinicians, faculty and staff members in the Armstrong Institute.

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Renee Demski

Renee Demski, M.S.W., M.B.A., is the vice president of quality for The Johns Hopkins Hospital, Johns Hopkins Health System and the Armstrong Institute for Patient Safety and Quality. She also serves as also interim vice president for patient safety and quality for Johns Hopkins Medicine.

9 thoughts on “After Surviving a Medical Error, Mike Armstrong Vowed ‘Never Again’”

  1. I share Mr. Armstrong’s passion! That’s why I’m pursuing my masters in Patient Safety and Quality at Johns Hopkins Bloomberg School of Public Health

  2. Amazing story, sad that many of us have our own. More amazing though, is that he had the vision to believe it could be different. And to that we all owe him a great deal.

  3. I am so happy you survived leukemia! My brother was not so lucky. He hadn't been feeling well and I encouraged him to see his physician. He lived about an hour away. I asked him for his bloodwork and tests results. He said all was ok. He finally agreed to come to Buffalo for another opinion. I reminded him to bring all test results. He left the results with my mother. I looked at the results of bloodwork when I came home and could not believe my eyes! The labs from 1 year ago showed off the charts WBC'S! I mean in the thousands. No one sent these horrific results to his physician nor did the physician follow-up. I worked in Oncology and my brother was seen the next day. Only to find out he had lung cancer. By the way, a chest ray or CT Scan was never ordered. Sad to say that after a few months of treatment, my brother died. He did not have a chance. PLEASE, follow-up with your physician when you have had tests. Physician's offices are busy places. And sometimes we think no news is good news. Always check. We were also sadly told that the original Dr would just get a slap on the wrist for his grave neglect. We were told that my brother was terminal anyway and that this would go nowhere with a terminal disease. We just did not want this to happen to anyone else. We must be our own advocates!

  4. Thank you for sharing your story and I can only imagine the mix of feelings you and your loved ones experienced as a result of this medical error. A misreading of a blood test led you through a long journey and yet this happens far too often. I'm happy to hear that you are well now. My family experienced medical oversight with my late father in 2016 - a CT scan taken at the emergency dept showing cancerous masses in both lungs was not shared with us. It was later revealed when I accompanied my father to a doctor's visit when the doctor asked if we were told about the lung masses by the emergency physician. To say I was shocked is putting it mildly especially as we had just lost our mother two weeks prior. Eventually, I did speak with the Chief of the ED who apologized for this serious oversight. Interestingly, I have devoted the past 20 years working with a nonprofit in New Haven, CT called the Institute for Healthcare Communication (www.healthcarecomm.org) where we provide CME and CE workshops for healthcare professionals on this very topic (Disclosing Medical Errors) and many others to improve communication. As you know, when communication is enhanced between the healthcare team and between clinicians and patients, patient safety is also enhanced. I'm a strong believer in sharing stories like yours so that we can achieve a level of [patient care for which we can all be proud. With gratitude and respect, Kathleen

  5. Fred J. Pane, R.Ph. FASHP, FABC

    I guess I have been involved with patient safety in my role as a pharmacist and pharmacy leadership position for almost 30 years. When I worked in a large IDN, we actually developed a patient safety video, to get patients and their families more involved in the process of safety and this almost 15 years ago or more. The biggest error I found, occurred in a friend and one of my staff that was diagnosed with non-Hodgkin's Lymphoma. A protocol that was recommended for him was printed incorrectly in a Peer reviewed oncology journal and no one report the error until I did 2 years after it was in print. I had to follow hospital procedure, notify the oncologist (who was a friend to both of us) and not tell the friend that I found the error, as he was exhibiting neurotoxicity. Deposition was interesting and I was a witness for the hospital and the patient. Luckily we didn't go to trial and they settled. I learned to not take protocols that are published or even investigational protocols for face value and assume the information is correct. We don't have the luxury in healthcare, to make mistakes. Thank you for allowing me to share. Fred

  6. Dear Mike,

    I am sorry to hear you had such a unimaginable experience

    Happy the fighter in you turned it into your life mission .

    God bless you,
    Idit Klimker-Rosen

  7. Millions of Americans are being harmed by the medical system, bad doctors and the worst nurses in history.

    The rest can''t speak out - the #440kMedicalAbuseDeathsIn2017 and #250kPerYEAR since who knows when, and it is our DUTY to speak out against 'trophy' educations and medicine that is slipping into the literal dark ages.

    1. I have been caring for a disabled brother for about seven years and the journey became a continual obstacle course of medical negligences . The second most offensive was when he was diagnosed with multiorgan dysfunction and sent to hospice when they refused to cleanup his meds and give his bone marrow the epogen necessary . My brother refused to die at the hand of business doctors and go to Hospice . Thanks to the grace of God and a few angels along the way he is still alive today . I brought him to Hopkins believing they would respect him . . His case needs to be examined by the Armstrong institute if their goal is an honest to goodness interest in patient care and not just myth making .

    2. Nurses couldn't work any harder or be more kind and compassionate to their patients. The physicians couldn't be any brighter and more caring. The issues with our health system are just that, system issues...not people issues.

      We all live and work in a system. It is the job of leadership is to work on the sytem, to improve it, with the help of those who work in it.

      Healthcare as a whole has pointed the finger at itself. Hence the continiuous improvement and YOY reduction in hospital acquired conditions. Immediate change and safety/quality improvement do not happen overnight. It is journey.

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