A strong patient safety advocate and great guy, Dennis Tribble of Baxa recently posted a moving blog about the Emily Jerry Foundation on the American Society of Health System Pharmacists website. I am very thankful for his efforts in continuing to promote our cause and giving the foundation a larger platform in order to reach many more people. I have copied an excerpt below which I think you’ll enjoy. A link to the full post follows…
A painful experience…
Created By: Tribble, Dennis On Wed, Oct 05, 2011 09:16 AM
I just did something that may be the bravest thing I ever did, or the stupidest… I relived my experience as the maker of a medication error in an article that will be published in Pharmacy Practice News. It’s amazing how clear that memory is, how immediate it is, and how it still affects me emotionally even just to talk about it. That memory is 31 years old.
I think I got started down this road as a result of spending the morning with Chris Jerry. If that name doesn’t ring a bell, he is the father of Emily Jerry, the little girl who died as the result of a tragic medication error in which 23.4% Sodium Chloride rather than 0.9% Sodium Chloride was used to reconstitute what would have been her very last, “just in case” dose of chemotherapy. Chris tells me that the radiological images showing her progress were just incredible; they had only decided to do this dose “to be certain there were no lingering cancer cells”.
Chris talked about Eric Cropp, who he has publicly forgiven, and with whom he speaks publicly about the importance of systems thinking in error prevention, as well as about the need for consideration for what Albert Wu has described as “the second victim” of a serious medical error, the healthcare provider who commits the error.
Talking about his experience brought me clearly back to the day that I learned that I had sacrificed care to the god of productivity, and very nearly killed two children. It is a mistake I never made again, but I was seriously impaired for several weeks after that.