109 East Orange St. Chagrin Falls, OH 44022 chris@emilyjerryfoundation.org 440.289.8662

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”.

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!

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/

Heartfelt Letter Received After Yesterday’s PharmCon Webinar

For about the past five years or so, I have been working with a great organization called Pharmcon, occasionally doing educational webinars, as I did yesterday afternoon, for pharmacists, pharmacy technicians, nurses, etc., about Emily’s Legacy and the vital lessons learned from the horrible tragedy that occurred in 2006.

After yesterday’s webinar, I received this very kind and heartfelt letter from the newest member of the Pharmcon team. Correspondence like this, truly inspires me to continue down this path that I believe was “chosen for me” and makes me feel as though the Emily Jerry Foundation is really affecting positive change, making a difference, and quite possibly saving some lives from preventable medical error. With that said, I find it quite ironic that this gentleman’s last name is “HOPE” because that is exactly the true blessing he has given me!

Chris,
I just wanted to take a moment to say, from the bottom of my heart, how much I appreciate your joining us today on our PharmCon webinar and sharing some of the more recent highlights from the Emily Jerry Foundation. I, too, believe that multiple miracles occurred on that day amidst incomprehensible tragedy and heartbreak. One of those miracles was you. As the newest team member at PharmCon, I was ecstatic to learn that we had a solid working relationship with you to communicate such a vital message on so many fronts.

Having served as the director for an ASHP accredited training program, I knew of Emily’s legacy, but it was only recently that I made the connection between Emily’s legacy and the positive changes that I see from state to state, especially within the arena of pharmacy technology education. I am a member of PTEC (Pharmacy Technician’s Educator’s Council) and have followed the dialogue surrounding pharmacy technician education requirements over the past several years. I am still appalled that, even within our profession, we find objections to ‘common sense’ at times.

It was an absolute honor to speak with you today! Consider this to be my own offer to be an “advocate for the advocate,” whether it be through my role with Kevin and our team at PharmCon or on a personal level.
Thank you!

KEVIN HOPE, RPH, BCNP
Clinical Pharmacy Education Specialist

Allegheny Health Network’s Medication Safety Summit Recap


Yesterday was such an amazing day at Allegheny Health Network’s Medication Safety Summit in Pittsburgh. I truly felt so privileged and humbled to give the keynote to help kick things off. I was also so grateful to spend the remainder of the day surrounded by so many “like minded” AHN clinician caregivers who are just as passionate as I am, to put an end preventable medication errors! Throughout the day we all participated in various educational activities relating to improving medication safety overall, root cause analysis, etc. From all of this wonderful collaboration and input from the various modalities at AHN, I felt like we all learned so much. Bottom line, I walked away from this stellar medication safety summit with such a re-energized sense of HOPE and inspiration, that by all of us continuing to rally together, we can one day soon, achieve my somewhat audacious goal of ZERO preventable medication errors! With that said, I would genuinely like to thank AHN’s Vice President of Pharmacy, Laura Mark, and her colleagues for not only making this very productive event happen but for truly “hitting it out of the park”!

Why Do I Also Consider Myself a Clinician/Caregiver Advocate?

Most people truly understand why I am so passionate about my ongoing advocacy efforts in patient safety and why it has been so important to me. They also seem to get why, over the years, I have felt so strongly about always striving to be an active part of the solution to preventable medical errors, not only through my work, but through the programming of The Emily Jerry Foundation. What some people often ask me though, who do not practice medicine, is exactly “why” I refer to myself not just as a patient safety advocate, but as a clinician/caregiver advocate, as well? The following, very kind and supportive email correspondence that I just received from a pharmacist this morning helps explain the answer to that question.

“I just wanted to say I’m so sorry for what happened with your daughter. I also think you are an inspiration for how you took the situation and have done such good things with it. I am a pharmacist and I see all too often companies not getting to the root of the problem. They only try to fix the face of the problem, not the cause. You are doing something so wonderful by trying to fix the broken system after the trauma you suffered—I have no words to express how wonderful that is. I also don’t have words to express my condolences and sorrow for your daughter–words can’t suffice for that type of pain, I’m so sorry. Best Wishes, Jan”

Announcing The Emily Jerry University for eLEARNING for Pharmacy Technicians

So excited about how well our meeting went with RxTOOLKIT and the Therapeutic Research Center (TRC) yesterday. Extremely pleased to say that our organizations came to an agreement to immediately begin moving forward on the final development and implementation of the Emily Jerry University for eLEARNING for pharmacy technicians. To start, we will be offering comprehensive online continuing education training for pharmacy technicians and core competency tracking in all aspects of hospital pharmacy.

Read more about this exciting new program here:
https://rxtoolkitelearning.com/about/dedication/

Upcoming Speaking Engagement at Texas Hospital Association

Really looking forward to heading to Austin, Texas for the next few days for another speaking engagement with the Texas Hospital Association! Here is an excerpt from their website discussing the goals and objectives of the program I will be taking part in.

Quality and Patient Safety Conference

April 25-26, 2017
Embassy Suites San Marcos
Hotel, Spa and Conference Center

This activity is jointly provided by AXIS Medical Education and The Texas Hospital Association.

Learning Objectives

1. Identify actionable methods that can be used to provide care to patients.
2. Review barriers to quality improvement.
3. Clarify common reporting complexities.
4. Define adequate measurement outcomes.
5. Describe the effects of patient aggression of both patient and staff safety.
6. Demonstrate how to use data to identify health disparities.
7. Identify features of a high reliability organization.
8. Discuss four guiding principles of Patient and Family Centered Care and their use in quality improvement.
9. Identify solutions to prevent medical errors.
10. Discuss best practices that are proven to minimize the “human error” component of medicine.
11. Identify three frequently reported preventable adverse events in Texas.

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.

St. Barnabas Hospital in NYC Shows Laser Focus on Patient Safety

Absolutely awesome day today speaking at St. Barnabas Hospital in NYC, where the clinician caregivers are all laser focused on patient and medication safety! St. Barnabas is a stellar example of a smaller hospital, with often limited resources, that has successfully created a true “culture of safety” at their medical facility with all of their incredible clinician caregivers. This type of culture ensures that every single one of their patients receiving healthcare have not only the best possible outcome during their course of treatment, it also significantly lowers the probability of tragic preventable medical errors from occurring.