Jail time, loss of licensure questioned

by Karen Blum

More than three decades later, Dennis Tribble, PharmD, is still haunted by the memory of one of the worst cases of his professional life. Now the chief pharmacy officer for Baxa Corporation, Dr. Tribble was at that time a pharmacist in a hospital he prefers not to name.

“I had been practicing for a number of years by that time. I failed to note that an adult dose of quinine had been prescribed for a pair of 10-year-old twins suffering from malaria. It put those kids into heart block and almost killed them,” said Dr. Tribble, his voice shaking.

What support did his hospital provide? “One of my bosses sat down with me and said, ‘I think you’ve already beat yourself up a whole lot more on this than I’m going to. You’re going to be a lot more careful, right?’ That was the extent of the counseling I got,” Dr. Tribble recalled. “To this day I look back on that incident in terror. I was functionally at less than half speed for about two weeks after that. I second-guessed every move I made. When this kind of thing happens, you don’t believe in yourself or in the quality of anything you do.”

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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.

Read the full blog post by clicking here.

I’m genuinely looking forward to giving my patient safety lecture to the accomplished staff of Union Hospital in Dover, Ohio next Wednesday morning, October 19th. The Emily Jerry Foundation is extremely proud and honored to work with medical facilities across the nation like Union Hospital. They are recognized among the top 5% of around 5,000 short-term, acute-care hospitals in the United States and have received both the HealthGrades 2011 Patient Safety Excellence Award, as well as, the 2011 Emergency Medicine Excellence Award.

Click here to learn more about Union Hospitals HealthGrades awards.

Below are some comments we received from attendees to our webinar that took place the morning of October 5, 2011. It seems we are truly making an impact with these presentations. I am very thankful for the opportunity, as well as for all those who took part in the event that provided feedback – both positive and negative. The positive feedback reinforces my drive to spread the message, while negative feedback usually provides constructive criticism which can be used to present a better and more effective delivery in the future. Thank You once again to PharmCon!

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It’s difficult when the law is one way but the employer choses to ignore the law because the “front line” is who gets in trouble, not the “desk jockeys”. Certification may be mandated, but that’s not necessarily what you get.

I wasn’t sure what to expect from this presentation but I thought the topic was very interesting. I think it was very well done and it’s great that Mr Jerry was able to participate and that there was info on the foundation and Second victims.

Great presentation.

Again, thank you for the enlightening presentation of Fate, Destiny: Life I am awakened to the power of patient safety, responsibility and personal healing. The sharing of those involved brought a smile to my face and a dance within my soul. Thank you.

Tragic situation for all parties involved. Shouldn’t the OH State Board of Pharmacy had some responsibility as well in the fact they did notm, at the time of the incident, regulate pharmacy technician?

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I think Eric Cropp was treated rather badley it was an error that any one could have done, the tech here was not focused on what she was doing also concentrated solutuons should be kept away from IV preperation areas seperated bins locked. The days we all come home from work with no errors are the best days

I saw the original webinar also. Wow, what a powerful, emotional story. Thanks!

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Best presentation in all respects that I have seen. Thank you.

Nice follow up to the other CE

Excellent program

2 ce programs please

Seemed very biased towards the pharmacist.

A Pharmacist must learn to prioritize tasks and not allow themselves to be rushed. Put a person with the name and think about the condition(s) being treated and how an error could affect the patient and family. If an error is made take ownership and responsibility for it and offer sincere apology for any potential negative outcome(s).

a sad and emotional situation for all involved

Very good presentation

great presentation

This is a very powerful story. It made me cry..

wow, how sobering

thank you

Very important topic medication error and the end results.

This is a story that needed to be told. Very informative and inspiring.

Excellent presentation!

excellent webinar !! It had a lot of information to think about!!

Its all about focus, staying aware that what we do isn’t just a list of tasks but a person at the receiving end of our work. Over worked and under staffing is becoming a broader issue and projects errors such as this horrific one.

This could have been avoided if basic safety procedures were instituted as policy in the hospital & followed to the letter.

This was one of the best CE’s I have ever participated in, and certainly the first time a CE has brought me to tears. The gravity of what we as pharmacists do everyday is huge, and we can not forget the human element of our job. Thank you so much for presenting this moving and informative CE. God bless Mr Jerry and Eric, as you will both be in my prayers.

this should be mandatory for every health care provider

I CAN SAY GOOD EXAMPLE OF REAL LIFE CE- MED ERRORS,

This was a wonderful CE. Thank you very much for putting everything you have out there to educate as on something that we have the potential of dealing with.

this is a very eye opening lesson that if we do not Love God above all, we can be doomed to such tragedy, that will humble us, for Eric, he loved his profession so much more than God. Mr Jerry’s Family was given the hardest test, but thank God he learned to forgive. They are characters in the story so we may all learn.

na

Excellent presentation- we all needed the reminder

Very moving! Thank you

My thanks to Mr. Cropp and Mr. Jerry for sharing such a painful time in both their lives. Their willingness to do so may protect many, many “Emilys” in the future.

A nearly identical error happened at our hospital in north carolina. Thank goodness the pharmacist, one of our best, did not go through anything comparable. The board just focused on making sure the hospital put into place systems that would prevent another error. We are still understaffed, though.

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I had the opportunity to tell Emily’s story to a great group of people at the Baxa Corporation. They are involved in designing and manufacturing technology that will truly change lives for the better. I can’t stress enough how thankful I am to them all. As a patient safety advocate I recognize that these are the people who are saving countless lives every single day. I truly appreciate the opportunity to visit their offices, and am excited about our relationship going forward. Check out the video of my speech below..

For Immediate Release

September 22, 2011

Patient-Safety Advocate Baxa Corporation Joins Forces with the Emily Jerry Foundation to Champion Pharmacy Safety Education and Legislation

Englewood, Colo. – “Fatal saline overdose.” Three words a parent never expects to hear. But Chris Jerry did. Jerry’s daughter Emily died when a pharmacy technician’s mistake resulted in a fatal dose of saline solution. Three years later, in 2009, Jerry founded the Emily Jerry Foundation, a non-profit foundation dedicated to the prevention of medical errors. Today, patient-safety advocate Baxa Corporation formally joins forces with the Emily Jerry Foundation to evangelize patient safety.

As an Emily Jerry Foundation partner, Baxa will collaborate with Chris Jerry, Foundation President and CEO, to increase public awareness of solutions that can reduce the rate of human errors. The Baxa pharmacy workflow management tool, DoseEdge®, through barcode verification of every drug ingredient, has prevented more than 339,500 dose preparation errors in US hospital pharmacies.

“The Emily Jerry Foundation’s mission of improving pharmacy safety and reducing the rate of human error matches the vision my father had over three decades ago when he founded Baxa,” commented Baxa CEO Greg Baldwin. “Every day the Baxa team works to develop innovative pharmacy technologies for safe medication handling and delivery. We embrace the opportunity to join forces with the Emily Jerry Foundation, to increase public awareness of automation technologies that can improve dose safety and save lives.”

Read the entire official Baxa News release about the Emily Jerry Foundation partnership by clicking here.

The Emily Jerry Foundation is very proud to announce the new partnership with Baxa Corporation. I have been working extremely hard to establish key partnerships with like minded individuals, organizations, and patient safety oriented technology manufacturers across the country like Baxa. Patient safety is a number one priority for the people at Baxa. Through the implementation of Baxa’s technology and products into the pharmacy workflow medical facilities across the nation can now significantly reduce the human-error component of medicine that can often lead to medication errors and similar tragedies like Emily’s. With that in mind, The Emily Jerry Foundation is genuinely looking forward to a very long and mutually beneficial relationship between our organizations.

I am looking forward to visiting Baxa Corporation this month to give presentations and to meet their team in Englewood Colorado. Additionally, I am scheduled to do a Satellite Symposium with Dennis Tribble, Baxa’s Chief Pharmacy Officer and Chief Technology officer, at the upcoming American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting in New Orleans this December.

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Last Week, I had the pleasure of performing another Continuing Education webinar with PharmCon. To view the webinar click on this link for FreeCe.com. The following are a list of comments and feedback we received on the event. Lots of great feedback and kind comments. I truly appreciate all the acknowledgements and am excited my story is helping to make a difference!

The following are results from a post-webinar survey…

– 84% of participants rated the Webinar Excellent overall
– 84% of participants rated the content Excellent
– 78% of participants rated the content to be Educational vs. Commercially biased
– 70% of participants thought it was rational to pass Emily’s Act in Ohio
– 68% of participants thought Emily’s Act had  a positive impact on Pharmacy Techs

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I received a very kind letter from Summa Healthcare’s Maria Giannakos regarding last week’s lecture. I wanted to share it with you all.

When I first contacted Christopher Jerry this past spring, my intent was a simple note of support and appreciation. Much time had passed since I had first wanted to contact him, but as both a new mom and a healthcare worker, I could not wait any longer…


Click here to Read the full letter.

August 25th live Webinar at 8:00 pm Eastern time.

Emily’s Act Revisited: The Pharmacist, The Family and the Medication Error That Changed Their Lives

Make sure to mark your calendar for this live webinar. This moving presentation spans the five years since Emily’s tragic death, and the changes that have resulted in the lives of the pharmacist, Eric Cropp and the father of Emily, Chris Jerry. Both Eric and Chris are co-presenting this webinar.

This presentation can be accessed on www.FreeCE.com and there is a $35 registration fee to non-members of the web site. All registration fees for this presentation are donated to the Emily Jerry Foundation. “Virtual” seats are limited, so go to www.FreeCE.com now and register. This presentation is also ACPE accredited for one live credit hour for pharmacists and pharmacy technicians.