Author Archives: The Emily Jerry Foundation

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

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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”.

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Bozeman Health’s 5th Annual Safety Summit Recap

Last week’s speaking engagement at Bozeman Health’s 5th Annual Safety Summit was an absolutely incredible experience! I gave nine lectures in two days, to well over 900 of their clinical staff, upper level administrators, safety coaches, etc.. Additionally, I also had the great privilege of an in depth tour of Bozeman’s pharmacy departments to see, first hand, their pharmacy workflow and how the pharmacists and pharmacy technicians always put medication safety first! I want to genuinely thank everyone at Bozeman Health from the bottom of my heart, for successfully implementing a true culture of safety, amongst ALL the amazing staff, at their healthcare facilities in Montana!

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Looking forward to Roundtable on Patient Safety in Washington D.C.


Really looking forward to heading to Washington D.C. again, the week after next, representing the Emily Jerry Foundation. I feel very humbled and privileged to have been invited to participate in the Roundtable on Patient Safety and Hospital Compounding on October 11th. We will all be working together to find comprehensive ways to save lives from preventable medication errors and put a stop to tragedies, like what happened, not only with my daughter Emily, but also with so many others, before they actually happen.

The Roundtable on Patient Safety and Hospital Compounding aims to bring together key stakeholders to review the last five years in hospital medication safety advances and clinical practices; consider where further refinements can benefit patients and providers; and to develop consensus recommendations that advance the next critical phase of best practices and research recommendations. If you would like to learn more about the Patient Safety Roundtable and what we are planning to accomplish during this very important meeting, please visit their website at: http://patientsafetyroundtable.org/background/

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Emily’s Legacy Lives on!

The Patient Safety Movement Foundation’s 5th Annual Patient Safety Science & Technology Summit in Dana Point, California

The Emily Jerry Foundation was honored to be represented by Christopher Jerry as part of the Pediatric Adverse Drug Event Panel discussion at the Patient Safety Movement Foundation (PSMF) on Feb. 4th during the 2017 Global Summit in California.  The preparation for this important event began at the beginning of December with the drafting of a comprehensive white paper, Actionable Patient Safety Solution (APPS). Click here to download the resulting Executive Summary Checklist associated with APPS.

Dr. Nathaniel M. Sims, friend and ally of EJF, headed up and organized this very important endeavor. Dr. Sims and Chris met in June 2013, when Chris gave a keynote session at the annual Association for the Advancement of Medical Instrumentation (AAMI) 2013 Conference and Expo entitled “Changing the Culture of Medicine-A Father’s Powerful Message”.  Dr. Sims asked Chris if he would be interested in participating in the Medication Errors Panel discussion at PSMF in 2014. The following is a short video that the PSMF produced, where Chris describes Emily’s story. The video was used to start the conversation. Additionally, you can also view the video of the entire Medication Errors Panel Discussion from 2014.

Three years later, flash forward to the Pediatric Adverse Drug Event Panel discussion this year, where the focus was put on saving the lives of the smallest and most vulnerable patients… babies and children. Due to the simple fact that their body weight is so variable, correctly determining the dosage and concentration for any medication is absolutely vital, and clinicians only have ONE opportunity to get it right or tragedies can occur—as in Emily Jerry’s case. Dr. Anne Lyren, Clinical Director of the SPS National Children’s Network, was the ideal moderator of this year’s panel discussion. Dr. Lyren played a vital role in establishing SPS’s Quality & Safety Program. At the beginning of this video, listen to Dr. Lyren’s opening remarks emphasizing how she truly feels about Emily’s legacy, and what we can all learn from what happened. It’s extremely powerful!

Here is a screen capture of the event during the panel discussion as we all discussed our roles in reducing medical errors and dramatically increasing patient safety.

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How our “Life Saving” Partnership with RxTOOLKIT Began


In the summer of 2014, Chuck DiTrapano, a highly esteemed pharmacist from Reading, Pennsylvania reached out to me via email. The following is an important excerpt from Chuck’s poignant message that truly made me believe that we had been brought together for a very distinct purpose.

“We share a passion to make medication preparation and administration safer for all hospital patients. You and I also share the unfortunate experience of losing a child. My boy, John Vincent DiTrapano, was born premature in 1977 when I was a young pharmacist. Unfortunately, the technology of the time only gave him 16 days on this earth. When he died, I committed the rest of my pharmacy career to his memory. I place his initials on every one of the hundreds of NICU infusion calculations that are performed at Reading (they are embedded in the template). It is imperative that we change the system! I have the knowledge, tools, and team to make a difference. I believe we can make a positive change for all the Emilys and Johns now and still to come.”


Then Chuck began to share with me his heartfelt story of how his advocacy journey, as well as, his life experience, led him to establish a very successful family owned and operated business called RxTOOLKIT. As an expert pharmacist, he went on to explain in detail his true determination and effort to prevent tragic medication errors like the one that claimed my beautiful daughter Emily’s life in 2006. Just like me, Chuck was horrified at the thought that preventable medical errors are now the third leading cause of death in America, claiming over 440,000 lives each and every year! As a leading pharmacist, he also knew that medication errors were responsible for the largest percentage of these preventable deaths. With that said, the following is the story of how RxTOOLKIT was actually born, in Chuck’s own words, and was taken from the early email correspondence we had regarding this important issue.

In 2004, I was a supervisor at Reading Hospital and saw a need for a more effective communication tool for our staff. I realized that there was a mountain of information needed in order for the staff pharmacists and myself to perform our jobs successfully in a fast paced environment. I also realized that this information had to be readily available and easy to reference. RxTOOLKIT was born. Having the correct information and the appropriate tools at our fingertips enhanced decision making, added consistency, and improved patient safety. That same year, we received the ISMP Cheers Award for our web-based application.

Over the last 10 years, besides adding literally hundreds of pages of information, we have added more than 20 different applications to RxTOOLKIT.com. Our tools are created by pharmacists through direct clinical experience and front line development. They are developed solely on needs and feedback of actual users (pharmacists, technicians, physicians, and nurses) and solve both the small and large problems that pharmacists face every day. We have developed specialized tools for the most difficult and fragile segments of our patient population, including pediatrics and the NICU. Our tools can be fully customized to meet the needs of any institution’s procedures or protocols. We continue to pursue a very aggressive development agenda.

We have just launched our brand new homepage(s) designed to illustrate the features and benefits of our web based applications. Our tools are designed and priced to help ALL patients regardless of hospital size, pharmacy capabilities, and financial constraints. We believe in our motto: Safety is Priceless, RxTOOLKIT makes it affordable.

We have also come to know Eric Cropp. I invited him to speak to our staff last year. I have been around long enough to witness tragedy and I am all too familiar with the second victim. I think it is important that he share his message—“this can happen to you”. It is so easy for even the best of professionals to get lulled into thinking “this can’t happen to me”. Although I have been spared a firsthand experience such as Eric’s, I have had “near misses”, two of which are forever embedded in my brain. After hearing Eric’s story, and getting to know him, we developed the blog medsafetyonline.org. Our goal for the blog is to increase focus on the second victim and improve patient and provider safety through the exchange of resources, ideas, and experiences within the pharmacy and clinical practice community. I believe that by expanding the dialog among health care professionals and sharing our stories we can help to increase education and make a difference from the inside out.

On November 11th of 2014, I flew to Philadelphia to meet Chuck, in person, and to give two lectures at Reading Hospital that he had arranged. The whole experience was absolutely amazing! What made it so special was the simple fact that I felt an immediate bond with Chuck because he appeared to be on exactly the same path I was, the guy was on a mission to save lives from preventable medication errors and ultimately put a stop to all of these senseless tragedies that occur with far too many patients, each and every year! Furthermore, he proved to me he was “walking the walk” when I was given an extensive tour of Reading Hospital. I subsequently learned that RxTOOLKIT software was deeply integrated into virtually every aspect of pharmacy operations at this enormous healthcare facility and had been clinically proven to prevent medication errors for almost ten years!

Shortly after my visit in 2014, Chuck and I began discussing, in detail, how our two organizations could collaborate and partner on the development of a pharmacy technician eLearning training program that would significantly improve the core competency of ALL pharmacy technicians across the United States if they enrolled and participated in the program for continuing education credits (CE). Hence, RxTOOLKIT eLearning was born (in BETA now!).

Please click here to read the very profound dedication they just made to my little Emily’s legacy!! As her Daddy, It’s in ways like these that I believe my beautiful baby girl will always live on!! I am so very proud of her! https://rxtoolkitelearning.com/about/dedication/

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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!

    Click Here to Read the Full Letter...

  • Our mission

    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.


    Thank You So Very Much for Your Support! ~Chris Jerry

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

    chris@emilyjerryfoundation.org


    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.