Emily’s story

Emily was diagnosed with a yolk sac tumor when she was about a year-and-a-half old.  The tumor was the size of a grapefruit inside her tiny little abdomen.  Even though our Emily was diagnosed with this frightening form of cancer, her team of doctors and nurses assured me that Emily’s cancer was not only treatable but highly curable!  Emily endured months of surgeries, grueling testing and rigorous chemotherapy sessions (which would last for five straight days).  If Emily’s blond ringlets had not fallen out due to the chemotherapy, no one would have been able to tell that she was even sick.  She maintained her sweet disposition and contagious little giggle through out all of her treatments.  Emily loved to play dress up with her big sister, Katherine, with all of their princess outfits!  Nate, her big brother, would read to her for hours and hours, the same books over and over.  How Katherine and Nate adored their little sister, Emily!

Emily’s treatment had been so successful that her last MRI clearly showed that the tumor miraculously disappeared. In fact, three radiologists had to review her MRI films due to the fact that there wasn’t even any residual scar tissue left. Emily’s doctors said it was as if she never had cancer!  Regardless she was scheduled to begin her last chemotherapy session on her second birthday, February 24, 2006.  This last treatment was just to be sure that there were no traces of cancer left inside of her little body.  We celebrated Emily’s second birthday in the hospital.  Some of her doctors and nurses had planned a surprise party for her and showered her with gifts, balloons and the whole works!  She had a constant flow of visitors to help with the celebration.  After Emily’s grandparents left, Nate and Katherine came with me bearing cupcakes for everyone on the floor.  I could not think of a better birthday present than being told that this was Emily’s last chemotherapy and she would be coming home cancer free!!  Emily would finally be able to live as a normal two year old!  Tragically, that never happened.

Sunday, February 26th was Emily’s third day of her last chemotherapy treatment.  It started out as any typical morning in the hospital.  Emily ate her breakfast while watching her favorite Barney episode as doctors and nurses made their morning rounds. Emily and her mom took a few laps around the floor with her IV equipment while she pedaled her big wheel with all of her might.  After playing in the activity room and scrubbing the play kitchen set with the nurses’ stash of alcohol swabs, it was time for lunch and an afternoon nap.  Emily’s grandparents stopped by for a brief visit. That was the last time they ever saw their little “Emmy” alive.

Emily-with-flowerEmily’s fatal dose was administered at 4:30 Sunday afternoon.  She woke up from her nap very groggy which was so out of character for her.  She kept trying to sit up and asked her mom to hold her in her lap.  As she picked her up to cuddle with her, she noticed how her little body was so listless.  She kept grabbing her head and moaning that it hurt.  Emily spotted her mother’s can of Coke that she had on the tray and begged to have a sip.  She sipped the rest of the can through the straw in a matter of seconds.  She cried for more before she started screaming, ‘Mommy, my head, my head hurts!  MY HEAD HURTS!  The whole time she was screaming she was holding the sides of her little head.  Her mother frantically called for the nurses as Emily began profusely vomiting.  I was just walking in as the nurses were grabbing her from her mom’s arms.  Emily went completely limp and the nurses began to resuscitate her.  Within seconds, there were doctors and nurses everywhere.  Emmy was rushed to the intensive care unit as the team was urgently attempting to find out what could possibly be going so very wrong.  Within the hour, my precious daughter, Emily, was on life support.

We held Emily’s little hand and ran along beside her bed as she was rushed to have CT scans and other tests to determine the extent of damage to her brain.  Since the life support machines could not go through the scans with her, the nurses climbed on the bed and manually kept her breathing during the testing.  This was so surreal to have this happening and still no answers as to why Emily was dying.  This couldn’t really be happening!  We should have been having dinner and talking with Nate and Katherine on the phone to make sure that they had their book bags packed and ready for school.  What was I going to tell Nate and Katherine?  The last time they saw their little sister alive was on her birthday, February 24th.  They were not allowed to visit on the weekend due to the cold and flu policy.  What a joke.  No one got any sleep that night.  We sat on Emmy’s bed holding her hands and kissing her little toes as the machines kept her body alive, hoping that we would wake up and this terrible nightmare would be over.  It never ended.  It just got worse.

The next morning the room was filled with strangers’ horror-filled faces as we were told of how my little angel, Emily wound up brain dead and on life support.  Her mom and I were told that even though she was still being kept alive by life support, Emily was essentially dead due to the massive brain damage she had incurred. Our Emily was killed by an overdose of sodium chloride in her chemotherapy IV bag.

Emily-Sepia-ChairWednesday, March 1st  was supposed to be a day of celebration.  Before entering the hospital, we had planned a belated birthday and a cancer-free party  for our Emily. Instead, our little Emily was delivered to the Cuyahoga County Morgue.

My family has been completely destroyed by the preventable and tragic death of sweet little Emily.  A pharmacy technician that had been working for the hospital for quite a number of years decided not to use a standard prepared bag of sodium chloride solution ( with less than 1% of sodium chloride solution).  Instead, the pharmacy technician filled a plastic bag with a concentrated sodium chloride solution of 23.4%  of which she had compounded herself.  When the pharmacy board investigators and other officials investigating Emily’s death asked the technician why she had made this outrageous error, she replied that she did not know.  She claimed that she knew that something was not right but she was not sure.  The pharmacy technician was asked if she knew that an overdose of sodium chloride could result in death. She claimed that she was not aware of that fact.  How can a person who works in a pharmacy and compounds medications daily not know that? At the time of Emily’s death, Ohio didn’t even register pharmacy technicians. In fact, there weren’t even any training or licensing  requirements.

Emily Jerry

Emily Jerry

Emily, Nate, and Katherine

Emily, Nate, and Katherine

Emily in the Sand

Emily in the Sand

Emily-Spoon

Emily-Drinking

Emily-Driveway

Emily-Dress-up

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74 Comments

  1. Joe Hughes
    Posted March 14, 2013 at 4:21 am | Permalink

    Chris,

    I was deeply moved by your story and thank you for sharing it at our Patient Safety Summit in CT last week.

    My mission is to help with instilling high reliability (HRO) values and help make our organization safer for all who are treated here by focuisng on patient safety related issues and a higher awareness of preoccupation with failure, increased accountability and best practices to minimize human error.

  2. Ashli
    Posted March 18, 2013 at 11:42 am | Permalink

    As a nursing student one of our assignments is to write an essay about medication errors and their danger. As I sit here reading your story tears are pouring down my face! I cannot imagine the heartache your family has gone through. That picture of your sweet Emily will stay in my memory forever and I will do everything humanly possible to prevent any medications errors that could occur in my career as a nurse. This story has touched me deeply and I am going to print it out and give it to all my class mates. Hopefully this story will prevent any one of us from making such a tragic mistake. I am so sorry for your loss. I hope that you can find some sort of comfort in the good that you are doing in your sweet daughters name.

    Ashli

  3. Andrew Knoch
    Posted April 2, 2013 at 5:09 pm | Permalink

    Mr Jerry I applaud you on your testimony to the Senate about SB 818. I am a father of three and I feel for your loss of your precious daughter. I spent a great deal of my evening last night writing every Senator to KILL the bill SB 818. I am literaly in tears after reading Emily’s story. We must do everything in our power to protect patients. I will take every opportunity I have to be an advocate for patient safety.

    As a pharmacist I could not agree more with you about keeping on eye on patient safety. It will be a long battle to prevent bills like this that benefit corporate greed.

    God Bless You

  4. Amber
    Posted April 19, 2013 at 4:58 pm | Permalink

    I am truly moved by your story. There are a lot of my family members who have been having treatment for cancers but knowing they’re older and can try harder to fight unlike Emily who didn’t have a chance after that horrible calculation of sodium chloride is just heartbreaking. I myself just foud out i have a brain tumor and have been having to make sure it hasn’t grown any, but it’s stil very scary. I’m doing a project at school about how chemotherapy is very harmful and I would like to share Emily’s story if that’s okay? I am again truly sorry and my heart goes out to you and your family.

  5. Tzvi Krasner
    Posted April 23, 2013 at 6:53 am | Permalink

    I am a Pharmacy Technician student in Michigan. To hear that a person who worked in a chemotherapy ward for several years would mix a bag for a child with a dose of Sodium Chloride that would kill an adult, then claim they didn’t know is completely ludicrous. There is absolutely no way on God’s Green Earth that technician didn’t know what they were doing. Over 20% concentration is just insane. You make a mistake that costs a two-year-old child their life, own up to it. Don’t hide behind the words of an eighth grader caught texting in class.

  6. Shannon
    Posted April 26, 2013 at 12:38 pm | Permalink

    My heart broke when I read your story. I could hear her little voice in my head and I am just in tears to think that she went through that. I am so sorry for your loss. My thoughts and prayers are with your family. I have 3 boys and I don’t know how I would make it through something like that.

  7. Frank Korfias
    Posted May 7, 2013 at 7:20 pm | Permalink

    Chris,

    It was so good to chat with you today at the airport. When you handed me your card I knew a sweet girl was no longer with us. My heart goes out to you and your family. I hope I can be of help to you as we share a common cause in different fields of science. God bless your family and Emily and God bless you in your work.

  8. Amy Carnes
    Posted June 11, 2013 at 10:33 pm | Permalink

    This deeply saddens me and breaks my heart!!!! I hope that hospital got sued! I’m so sorry for the families loss!! Such a darling little girl!!!!

  9. E Nget
    Posted June 18, 2013 at 4:23 am | Permalink

    I am so so sorry for loosing such an angel due to humanly and technical negligence on those that we trust our lives in. It is just unfortunate.

  10. Amy
    Posted July 9, 2013 at 6:26 pm | Permalink

    I heard about your sweet baby girls story at my patient services orientation for new employees at Children’s Mercy, in Kansas City, today. It was heartbreaking and eye opening at the same time. They used your story as a template for how even the smallest errors can bring so much harm and how this error should have never been missed if the system had been in place. Im so sorry your baby became a story for this but I truly believe her story alone will change the lives of many.

  11. joshua
    Posted July 29, 2013 at 11:24 pm | Permalink

    Joshua-
    I am a pharm-tech student currently, and am doing a paper on med errors, Emily’s story is shocking, and heart wrenching. I am appalled that anyone would/could get away with something so terrible. As a soon to be father I can not imagine the pain that you and your family must have gone through. I am encouraged by your strength in telling Emily’s story. I pray that because of this that all states increase the standard of education required for all medical fields.

  12. Aminah
    Posted August 13, 2013 at 6:30 am | Permalink

    I cannot even begin to tell you how sorry I am to hear about your loss. I am a pharmacy technician, and I completely understand the role that we play in hospitals, is actually crucial. In Ontario, Canada where I live we have now implemented new laws that require all pharmacy technicians to be licensed and our field is regulated under the College of Pharmacist. We have more training and do everything we can to prevent medication errors. I was upset to read that the Pharm Tech had no idea what she did was wrong, it was very obvious and preventable. They should be trained better. I now train pharmacy assistants and tell them your story, so they will do every thing they can to prevent another Emily.

    My prayers are with you.

    A.

  13. Jillian
    Posted August 27, 2013 at 10:54 am | Permalink

    I am so sorry about all that you have gone through. I want you to know that through your efforts, you have made a difference that is still effecting people. I am in my second week of nursing school at Forsyth Tech in North Carolina, and we learned of this story as a way to know the seriousness of using medications and what can happen if you make any errors. Though I wish it never had to reach that point, I am confident that this will serve as a reminder for all in the medical field, and will save lives by making everyone more cautious of their actions. Again I am so sorry for your loss, I can’t even imagine what you have had and are stilling having to go through. My prayers are with you and may God bless you abundantly.

  14. Crissy Jaquez
    Posted September 20, 2013 at 11:23 am | Permalink

    Thank you for sharing your story with us! I truly wish it had a different ending but i have tears running down my face and I will always remember this story. Im in nursing school and i will pray to God that people in the medical field are held accountable for their actions. I will keep you & Emily in my prayers. Im still in shock and im sooo sorry this happened to u. May God bless you and your family and I know God will turn this bad around and use it for good in some way. Trust in God and do not lean on your own understandings. She is in heaven looking down at you and you two will be together again someday! Again sorry

  15. Brittney Baldwin
    Posted September 20, 2013 at 3:47 pm | Permalink

    I am a first semester nursing student who is doing research for medication articles, and I just so happened to study upon your blog. I am weeping. My assignment has been to investigate medication errors, the different types of them that were made, and what could be done to prevent them. There are so many things in this situation that could have been caught by the medical personal on staff. Stories like this not only break my heart, but also encourage me to be a critical care thinking nurse who does not just do something simply because she is told to. I am going to write a paper to submit to my nursing instructor about what happened to your daughter. What a precious life that was taken from us so soon. I am so thankful you shared this with the rest of the world, and I hope that by the time I hit the floor as a RN, we will be well educated in the medications we are administering, and learn to trust our instincts. I am sure that pharmacy tech will live with a tremendous amount of guilt for the rest of her life. Its truly sad for both parties. My condolences.

  16. Brian Bowlin
    Posted November 5, 2013 at 7:49 pm | Permalink

    Mr. Jerry, I heard you speak today in Montebello, CA and the story of your beautiful daughter profoundly affected me. I applaud your willingness to speak out about this tragedy. Keep up the good work of the Foundation. I’m planning on meeting with our pharmacy staff first thing tomorrow to share Emily’s story. God bless you and Lisa!

  17. Posted November 9, 2013 at 8:34 am | Permalink

    I can’t stop sobbing.

  18. Tiffany Anderson
    Posted November 12, 2013 at 10:35 am | Permalink

    I am currently a Pharmacy Technician student, our book that we study out of is dedicated to Emily Jerry. I am truly sorry for your lost. Her story has deeply touch me. I pray for comfort, strength, and blessing for your family.

  19. Arie Spitzfaden
    Posted November 18, 2013 at 8:45 pm | Permalink

    Chris Jerry,
    I have been moved by the loss of your daughter for some time now. I am a former hospital pharmacy clinical manager and later served as director. One of the tasks that I had while serving in these roles was to orient new nurses on “Patient Safety”. I always told your story to grab the attention of these new nurses. I wanted to instill the value of critical y thinking as they performed nursing duties. I always included photos of Emily in the presentation to put a face on the importance of critical thinking. I have since relocated to another town to be closer to my daughter and grandchildren. I now have been tasked to speak to pharmacy students on medication errors. Again, your story will be brought to the forefront of these student’s minds. I hope in some small way, me telling your story helps prevent future fatal errors with healthcare professionals. I sincerely wish you and your family peace. I also wish you continued success in the fight against medication errors.

  20. Ginny Renkiewicz
    Posted January 6, 2014 at 9:10 am | Permalink

    Despite being an in-hospital error, we are using the youtube video and your story to train Paramedics and EMTs during their pharmacology training. Far too often are they taught that certain drugs are “safe”, which couldn’t be further from the truth. All of them have the potential to be extremely dangerous and life-threatening, period, whether they are administered incorrectly or not. Believe me, every student I have knows your daughter’s sweet face, and what happened to her is helping to train others in a different field.

  21. Sara Wright
    Posted March 6, 2014 at 2:18 pm | Permalink

    I am a first year med student and we were assigned to learn about Emily’s Law, due to medical/human error and the unbearable consequences. I am so deeply touched by this story because I have a two year old of my own and I couldn’t imagine the pain. My heart goes out to the family because this should have never happened, but Emily is a beautiful angel now and her story is not just that but it is saving lives probably every day. I can promise you as I make my transition into my career I will hold Emily’s sweet little life close to me knowing that I have to be absolutely accurate on everything I do.

  22. Jennifer Hernandez
    Posted March 26, 2014 at 7:25 am | Permalink

    I was truly speechless, after reading this story about Emily. I’m studying to become a Pharmacy Technician and it’s a reality check to me. It demonstrates to me that I really gotta study and know what I’m studying and take every patients that I’m going to work seriously. These seems horrible to happen to a child but to have that Pharamacy Tech say she didn’t know this could happen, seems as if she doesn’t have the knowledge about compounding solutions.

    I’m truly sorry for your lose and God bless the family.

  23. Posted March 28, 2014 at 8:25 pm | Permalink

    my daughter was drugged beyond belief.

    besides suffering every minute of every hour of everyday, I am now beint threatened by The Doctors Company, to have all my possessions taken from me. We took one doctor to court and she won. The jury, some of them on opiates themselves, just were manipulated by a lawyer and firm called Taylor Blessey. My Tara is gone. My son now suffers, Tara’s father is a shell of a man, and my relationships with people and the world are not longer safe or the same.

  24. Lauren
    Posted July 27, 2014 at 9:03 pm | Permalink

    I am a pharmacy technician and first heard of Emily during my technician training program. In my position I work on a computer and never see patients, and it can be easy to forget or to overlook that there are real people on the receiving end of our computer work. Mistakes in this field, whether you’re a CPhT or a PharmD can end lives. This is why I keep a photo of Emily in my cubicle. That may seem extreme to some, but I feel that seeing her face everyday can keep me more focused and help prevent mistakes from being made. When a simple mistake, even one of just one character entered incorrectly into a computer system, could cause so much pain and suffering I feel it’s best to do anything possible to keep focus. Emily keeps me focused.

    Also, I work in Ohio but used to work in Indiana where we were required to have an FBI background check and obtain a license form the Professional Licensing Agency to practice as technicians. I’d love to help make that the law in Ohio. The fact that there is no licensing in this state is disturbing and negligent. I’d also like the law to require that all future pharmacy technicians must complete an ASHP-accredited pharmacy technician training program before being able to work as a pharmacy technician. I’d love to know how to get involved with making this happen. If you’d like to e-mail me that would be great.

    The company I work for maintains a 99.996% accuracy rate. That still means that 40 of every 1 million prescriptions we fill contains some kind of error. I think that’s too high. Maintaining focus, keeping perspective by keeping our patients in mind when we work, and mandatory education and licensing for pharmacy technicians could maybe see this accuracy rate increased to 99.9996%. 40 per million is too high. 4 per million is still too much, but with 4 per million the chances of a serious med error resulting in injury or death is reduced to almost 0.

2 Trackbacks

  1. By Preventing Medical Errors | Annotary on August 27, 2013 at 5:10 pm

    [...] story: toddler beats cancer and then ODs due to tech error emilyjerryfoundation.org Paige Leavitt 0 minutes ago Sort [...]

  2. [...] As an illustration of the variability of quality, the Emily Jerry Foundation recently released its “2013 National Pharmacy Technician Regulation Scorecard”. The development of this scorecard was prompted by the heartbreaking story of what happened to two year old Emily Jerry. [...]

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  • Nate & Katherine

    A Letter to My Children

    Dear Nate & Katherine,

    I truly love and miss, both of you, more than you will ever know! I am so incredibly sorry that you both have had to endure the loss of your baby sister, the death of your uncle, and the breakup of your family in such a short period of time. You both were the absolute best big brother and sister ever and I know how much you both must still hurt and miss her! I genuinely hope and pray that you find some comfort and that you both always know in your heart that little Emily is still watching over all of us!

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    The Emily Jerry Foundation is determined to help make our nation’s, world renowned, medical facilities safer for everyone, beginning with our babies and children. We are accomplishing this very important objective by focusing on increasing public awareness of key patient safety related issues and identifying technology and best practices that are proven to minimize the “human error” component of medicine. Through our ongoing efforts The Emily Jerry Foundation is working hard to save lives every day.


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    We'd love to hear your stories and comments. Together we can save lives.

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    Advocacy Heals U


    Internet Radio Show Co-hosted by Joni Aldrich and Chris Jerry of the Emily Jerry Foundation

    Through my work as an advocate, I never really knew the profound healing that would occur on a personal level, as Emily’s father. It’s this type of healing process that can occur, for anyone who has experienced or is going through a life-changing crisis, that cohost Joni Aldrich (www.jonialdrich.com) and I, discuss on our weekly show called ADVOCACY HEALS U. Please join us every Tuesday at 2:00pm EST and find out how to be an advocate for positive change and how it can, subsequently, heal and inspire you too! Over any web enabled device, you can listen to the show by either going to www.W4CS.com or www.W4WN.com. If you happen to miss a show it will be rebroadcast each Saturday at 3:00pm EST. All our shows are archived on iHeartRadio.com. Click on the button below to scroll through the archives.

  • Form Letters

    Medication Safety Form Letters

    A few months ago, we introduced The Emily Jerry Foundation’s National Pharmacy Technician Initiative and Scorecard. Our new interactive scorecard’s primary objective is meant to be a useful tool for everyone in the public to use to protect themselves, their families, and their loved ones, from tragic and often deadly medication errors, like the one that took my beautiful daughter, Emily’s, life in 2006. As with Emily, these types of tragedies often occur in states that have little to NO oversight or continuing education requirements for their pharmacy technicians. If you live in one of these states that has absolutely no requirements for their pharmacy technicians, has received a poor grade on our scorecard, or if you are simply not comfortable with the potential core competency or training requirements of the pharmacy technicians in your state, I would urge you to complete and print out the following two letters and get them signed. These letters could ultimately save your life, or the lives of the ones you love.

    One of the letters was written for those of you who will be receiving treatment at a hospital or medical facility that will be dispensing and compounding medications for you in their clinical pharmacy. The other letter is for those of you that will be receiving your medications from a retail pharmacy close to home. Many of you will need to utilize both letters, due to the fact you will be receiving various medications from both types of pharmacies (clinical and retail) during the course of your treatment.

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