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Month: October 2017

Roundtable on Patient Safety in Washington D.C. Pushes for Improvements in Hospital Compounding


I felt very privileged to be asked to give the keynote address and to participate in this very important Roundtable on Patient Safety in Washington D.C. last week! The meeting was organized to bring together key stakeholders, leading pharmacy experts, representatives from the FDA, Joint Commission, AHA, etc., to review and discuss the last five years in hospital medication safety and clinical practices. The primary objective at the end of the day, which I felt was definitely accomplished, was to have found where further improvement can be made in hospital compounding, discuss possible refinements in best practices, and to reach a consensus on the leading practice recommendations. By all of us rallying together to advance patient safety overall in a very well organized forum like this, I really believe that, together, we will ultimately save countless lives from preventable medication errors!

The following is the press release that went out last week over the PRnewswire:

Five Years After NECC, Experts Review the State of Hospital Compounding and Patient Safety

Addressing the Human Error Component in Medicine – The Real Solution to Ending Tragic Preventable Medical Errors!

“We must accept human error as inevitable – and design around that fact.” ~Donald Berwick

Ever since my daughter Emily Jerry’s tragic death 11 years ago from a preventable medication error, I began an unintentional quest, that I believe was chosen for me, to work diligently to affect positive change in medicine. Over the years, I have had the opportunity to work with some of the brightest minds in healthcare and have always strived to help transform the culture of medicine, how it’s practiced in the U.S., and more importantly how we respond and learn from these preventable medical errors which have now been identified as the third leading cause of death in the United States.

I founded the Emily Jerry Foundation, in honor of my daughter’s short life here on earth, to focus on the modification of underlying systems, processes, and protocols in medicine, and to find comprehensive solutions that would minimize the probability of this inherent “human error component of medicine.”

Naturally, many people have often asked me, what is the primary cause of preventable medical error that makes it the third leading cause of death in the United States with such an astounding loss of life every year? The answer is really quite simple…it’s this inherent “human error” component of medicine. The fact that every single well intended clinician, no matter how vigilant, compassionate, or empathetic they may be towards the patients they care for on a day to day basis, is capable of making a “human error”. This is precisely why the focus of my work over the past decade, since the tragic loss of my daughter Emily in 2006, has been on saving lives through the modification of internal systems, processes, and protocols in medicine. This is also why I have been such an outspoken proponent for the smart implementation and adoption of clinically proven technology, as the tools, to significantly reduce, if not completely eliminate, the probability of “human error” from creeping into the equation during the course of treatment, for ALL patients. As Steve Jobs so eloquently put it, “Technology does not have human flaws”.

 

The Journal of Patient Safety (September 2013 – Volume 9 – Issue 3 – p 122–128) titled “A New, Evidence-based Estimate of Patient Harms Associated with Hospital Care”.