Shortly after my two-year old daughter, Emily’s, tragic death in 2006, I began this journey I’m currently on as a full time patient safety advocate. As it still is today, my primary emphasis when I first began my advocacy efforts, was to focus on ways to influence positive change in our nation’s medical facilities that would help minimize the probability of “human error” occurring, on the part of caregivers in medicine. My thought, when I first started, was simple. If I could put all of my time and energy as an advocate, each and every day, into this one particular area of preventable medical errors, ultimately it might end up saving others from a similar fate as my beautiful Emily. I felt very strongly that if this work that I had chosen to do as an advocate, ended up saving only a few lives over the course of time, then all of the hard work would be worth it. More importantly, I couldn’t think of a better way to honor my daughter Emily’ short life. Additionally, I truly thought these efforts would make her tragic death less senseless.

Through this work as an advocate, I never really knew the profound healing that would occur for me on a personal level, as Emily’s father. I now believe that this is just one of the many blessings given to me by my little girl. 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, will be discussing on our new 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.

Click Here to Listen to the “Advocacy Heals U” Audio Promo!

On the Morning of May 8th I was honored to give the keynote presentation at Kroger Pharmacy’s Annual Medication Safety Summit in Cincinnati at, of all places, Paul Brown Stadium (I honestly didn’t even realize it was going to be there until the night before the event!). Due to the fact that over the past few years I’ve been focussing all of my time related to medication safety, on clinical pharmacy, I honestly didn’t think too highly of retail pharmacy in general. To make matters even worse, I had such negative experiences recently with the Walgreens lobbyists in the Florida Senate, over my opposition to Florida’s SB818.

I must say that Kroger Pharmacy changed ALL of my negative opinions and thoughts during the course of this engagement! Every single pharmacist, pharmacy technician, and upper level management person I met, I now consider the “rockstars” of retail pharmacy! Kroger Pharmacy is the new “Gold standard” in my mind, for putting their customer’s safety, BEFORE profits. I will subsequently use their example for the other retail pharmacy chains, in terms of my core expectations, going forward!

As you can tell, I was pretty impressed with what I found within the Kroger Pharmacy culture. The feeling was mutual as attendees of the event seemed to be truly touched by my story as well. Below are some very kind notes I received as a result of the presentation. This kind of feedback really inspires me to keep moving forward, inching closer to the goal every day of safer standards for our patients, and reducing the human error component of medicine.

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Dear Mr. Jerry,

My name is Casey and I met you this week when you spoke to the group of pharmacy managers and lead technicians for the Kroger Company in Cincinnati.  I would first like to thank you again for sharing your story with us and commend you for your strength and compassion.  It is rare to have such powerful qualities in the face of such adversity and I can only pray to have a fraction of those qualities for myself.

I cannot express exactly how much Emily’s life and story moved me. As a new parent, this story was especially impactful, and I again marvel at your courage.  Your work in advocating medication safety is admirable in itself, but is exponentially more moving when the tragedy of Emily’s death is added.  I am a member of our division’s Medication Safety Committee and it is extraordinary to me that anyone outside of the pharmacy profession would work so passionately to enhance our practice.  Patient safety has always been a focus of mine and I hope to instill that in every member of my staff.  I was hoping you could direct me to where I could find the video clip you showed us at the beginning of your presentation.  I conduct quarterly staff meetings and I would like to show my staff the video and share Emily’s story with them at our next meeting.  I would like to use any means available to impress upon my staff the importance of the work they do and how impactful it can be.

Also, I would like you to know that in an effort to make our pharmacy as safe as it can possibly be, I have banned all use of cell phones within the pharmacy.  It is a small step, but a change I could make quickly and something I feel will be very impactful on the focus of attention for my staff.

Again, I thank you for sharing  your story and wish you the best in your endeavors in patient safety advocacy.

With thanks,

Casey Guilfoyle, PharmD, RPh

Pharmacy Manager
Kroger Co., Store 418

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We are thankful for our friends at Pharmacy Purchasing & Products for highlighting our Emily Jerry Foundation Safe Label Program in their April 2013 edition. A small blurb appears on page 28/29 of the digital edition which can be viewed online by clicking here. The program incorporates the Blue Angel logo into software systems that print the medication labels. This image will help identify medications that are meant for children and need to be handled with the utmost care and precaution. This will in turn help lessen the human error component of medicine. We are very excited for the progresss of this program, as Medi-Dose/EPS took the first step, and we are now working on adding other manufacturers such as Codonics (whom we are in talks with currently) to add this safety feature to their technology as well.

The following is an update on Florida’s pending Pharmacy Staffing Law – Senate Bill 818. Again, this irresponsible and deadly legislation was initially drafted by Senator Rene Garcia who obviously has a reckless disregard for the residents of the state of Florida, whose lives will be put in grave danger from medication errors, similar to my daughter Emily’s, if this ridiculous bill ends up getting passed! It’s time like these we need to hope the American system of government “by the people, for the people” will shine through. It is of the utmost importance that each and every Floridian and other concerned citizens around the nation contact these legislators and let their voices be heard.

Click here to read the ‘Health News Florida’ story.

The past few days in Tallahassee were long, but very productive. On Monday April 1st, the day began with a press conference in the Capitol Rotunda. You can see some local media coverage from WCTV Tallhassee of the press conference by clicking here.

Later that morning, the three gentleman below and myself visited and spoke individually with the members of the Senate Health Policy Committee to discuss the reasoning behind our strong opposition to Senate Bill 818. Larry Gonzalez (pictured next to me) is a lobbyist for the Florida Society of Health System Pharmacists, George Malone is a Pharmacist and Director Pharmacy, as is, Mike Putze (pictured far right).

On Tuesday we had the Senate hearing and unfortunately, due to time constraints, the senate was not able to vote on SB818 and said that they would be addressing the bill during their next session on Tuesday April 9th. With that being said, I believe they were only trying to appease me that day and prevent me from providing my full testimony in opposition of this ludicrous bill, by giving me only a minute at the end of the session. For that reason, I am planning on flying back to Florida this Monday so that I can provide my full testimony. You can view my minute of testimony and see exactly how the legislators in Florida operate, with respect to these types of very important issues seriously affecting the public safety of the residents of their state, by clicking here to visit the official Florida Senate Video Archive. I was given about a minute to present my testimony at the 174.35 time stamp. Please fast forward through the video to that time to see the pertinent clip.

During the senate hearing we did hear some good news regarding the Florida State Pharmacy Board. Prior to our work last week, they were actually supporting the passage SB818. In my limited opinion, the only reason I believe they were in support of this bill initially, was simply due to the fact that a few of their board members are currently employed by Walgreens. Because a few of these board members receive a paycheck from Walgreens, I think this was the ONLY reason they were able to temporarily sway the other, upstanding members of the Florida State Pharmacy Board. By initially supporting this bill they were NOT accomplishing their core obligation to the public they serve, which is protecting the residents of their state from unsafe pharmacy practice and supporting a very deadly piece of legislation like SB818. With that being said I am very pleased to announce that, during this hearing, we received word that the Florida State Board of Pharmacy was WITHDRAWING their support of SB818! Bottom line if this bill, STILL, successfully passes through the Florida Senate, next Tuesday April 9th, then those Senators on the Senate Health Committee who end up voting in favor of SB818, need to be held accountable for ALL of the medication errors and subsequent deaths that will occur if it’s passed! Furthermore, those who vote in favor of SB818, ignoring what the experts in pharmacy, including their own State Board of Pharmacy, are saying that by increasing the pharmacy technician to pharmacist ratio to 6:1 is an EXTREMELY UNSAFE pharmacy practice, are truly not looking out for the best interest of their residents and actually putting them in harms way. Thus, they will be putting organizations like Walgreens PROFITS before the public safety of ALL of the Florida residents, including their own families and loved ones!

For those of you in the public who have friends and family in Florida and especially those who live in Florida I urge you to immediately contact ALL of the members of the Florida Senate Health Policy Committee (listed below), as soon as possible, and help voice your strong opposition to this DEADLY sentate bill SB818! Please help The Emily Jerry Foundation KILL SB818 before it KILLS the residents of the state of Florida!

SENATE HEALTH POLICY COMMITTEE

Aaron Bean
R-4th District
Fernandina Beach
Tallahassee Phone: (850) 487-5004
Email: [email protected]

Jeff Brandes
R-22nd District
St. Petersburg
District Phone: (727) 552-2745
Tallahassee Phone: (850) 487-5022
Email: [email protected]

Oscar Braynon
D-36th District
Miami Gardens
District Phone: (305) 654-7150
Tallahassee Phone: (850) 487-5036
Email: [email protected]

Anitere Flores
R-37th District
Miami
District Phone: (305) 270-6550
Tallahassee Phone: (850) 487-5037
Email: [email protected]

Bill Galvano
R-26th District
Bradenton
District Phone: (941) 741-3401
Tallahassee Phone: (850) 487-5026
Email: [email protected]

Rene Garcia
R-38th District
Hialeah
District Phone: (305) 364-3100
Tallahassee Phone: (850) 487-5038
Email: [email protected]

Denise Grimsley
R-21st District
Sebring
District Phone: (863) 386-6016
Tallahassee Phone: (850) 487-5021
Email: [email protected]

Arthenia Joyner
D-19th District
Tampa
District Phone: (813) 233-4277
Tallahassee Phone: (850) 487-5019
Email: [email protected]

Eleanor Sobel
D-33rd District
Hollywood
District Phone: (954) 924-3693
Tallahassee Phone: (850) 487-5033
Email: [email protected]

UPDATE: Local Florida News channel WCTV Tallahassee covered today’s press conference and testimony before the Florida House and Senate where I spoke out against the bills increasing the pharmacy tech to Pharmacist ratio.To read the full story and watch the video news coverage on the WCTV website click here.

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On Tuesday April 2nd, I will be testifying before the Senate Health Policy Committee in Tallahassee to tell my daughter Emily’s tragic story and voice my strong opposition over SB818/HB671. If this ludicrous bill passes, it will increase the technician to pharmacist supervision ratio to six to one. If this happens, Florida residents will be put at a much greater risk of tragic medication errors similar to the one that heartbreakingly took Emily’s life.

What really upsets me about this horrible piece of legislation, is that the ONLY people and organizations who ultimately benefit from this type of legislation passing, are the big retail pharmacy chains PROFITS, like Walgreen’s, etc. Their underlying motivation for lobbying so hard for these increased pharmacy technician to pharmacist ratios, is simply due to the fact that it costs substantially less for them to staff their profit generating pharmacies with as few salaried pharmacists as possible, having them supervising as many, hourly paid, pharmacy technicians as the law will allow. What’s most disturbing to me is the fact that these retail pharmacy chains are constantly putting their profits before their customer’s safety. In doing so, they treat their pharmacy technicians as unskilled, hourly labor. Putting them into a high volume based production line type environment, where there is a propensity for catastrophic human error that ultimately results in medication errors occurring. Evidence of this is that over the past six years, Florida has been the site of several very well publicized and tragic pharmacy technician related errors, which resulted in patient deaths and injuries.

• From Jacksonville Florida – Inside a pharmacy where a fatal error occurred

• From Lakeland Florida – an ABC 20/20 news story describing this case: Walgreens Told to Pay $25.8 Million Over Teen Pharmacy Tech’s Error

• Other errors are detailed here

With all of this being said, I am appalled with the fact that the Florida State Pharmacy Board is actually supporting the passage of this ridiculous bill that will have tragic consequences for the residents of their state. Any state board of pharmacy’s primary mission is to protect the residents of their state from unsafe pharmacy practice. This raises an important question, do they really feel that by increasing the pharmacy technician to pharmacist ratio they are actually accomplishing their mission and adequately protecting their residents from this clearly unsafe pharmacy practice? Along those lines, I find it very hard to believe that Representative Travis Hutson (R), as well as, the members of the Florida Health & Human Services Committee who sponsored this horrible piece of legislation really DO NOT have their constituents best interest in mind. It really appears as though they are doing nothing more than lobbying for the retail pharmacy chains and their profits. I question why they have seem to have absolutely no compassion or empathy, at all, for the wellbeing and safety of the residents they all represent in the state of Florida. If they genuinely had the public’s safety in mind, and not the best interests of the retail pharmacy chains profits in mind, they might consider keeping pharmacy technician to pharmacist ratios where they currently are. Additionally, in my opinion, people like Representative Travis Hutson, would consider introducing legislation requiring retail pharmacy chains in the state of Florida to staff their pharmacies with more pharmacists, basing the number of required pharmacists on duty predicated on the volume of prescriptions being filled.

Some Additional Factors that Should Concern Florida Legislators and The Public They Serve

1)  In 2011, California, New York, Florida, and Texas are the four leading states with the highest number of retail prescriptions filled.  California has a 1:1 technician to pharmacist ratio, while New York and Texas have a 2:1 ratio.  Florida is currently at 3:1.  Currently, Indiana and Idaho are the only two states that allow a 6:1 ratio, with each state filling approximately 30% and 8% respectively, of Florida’s total number of prescriptions.  The table below compares the ratios and volume done for each state.  HB 671 allows increasing of the technician to pharmacist ratio, which will expand the workload on pharmacists with high volume stores, leading to an increased risk of medication errors and lack of patient safety.



If this legislation passes, Florida would become the only high volume prescription state (third leading) with a highest pharmacy technician to pharmacist ratio. 

2) According to a report done in 2008 by the Institute of Medicine, medical errors in the United States range from $37-$50 billion.  Of that total, $17-$29 billion could have been a preventable adverse event. A systematic observational analysis of pharmacies in six large cities (Chicago, Los Angeles, Dallas-Fort Worth, Philadelphia, Seattle, and Tampa) revealed an error rate of 1.7% meaning four errors per day with a daily volume of 250 prescriptions.  By approving HB 671, this will increase the number of prescriptions a pharmacist must check daily, thereby escalating the error rate and preventable costs associated with the adverse drug event.

3) Studies done at Auburn University and Texas Tech documented that the risk of error rises along with the number of prescriptions filled per hour.  These studies showed that pharmacist’s error rate is volume dependent.  Pharmacists who are pushed beyond the limits also have less time to properly consult their patients. Consultation has been shown to decrease the risk of the patient leaving with the incorrect drug by 88%. .

Studies show that medication errors occur on a daily basis in the State of Florida and other states. HB 671 and SB 818 do not provide any benefit to the state or local governments in Florida. Both bills do nothing for the citizens or patients in the State of Florida except require that the pharmacist check the work of twice as many pharmacy technicians as before. This would cause greater medication errors affecting patient safety and lead to greater morbidity and mortality. So who does HB 671 and SB 818 benefit?  Why would any legislator sponsor such bills? Unfortunately, it seems to benefit only the special interests and large chain pharmacies in Florida to increase their profits and bottom line. What does it do for the citizens in Florida?  It creates a less safe environment to get their prescriptions filled and increases the risk of more medication errors.

The profession of pharmacy is often times referred to as the most trusted profession. This is because the public sees that the pharmacist is accessible, strives to provide the best care at the most responsible cost. The pharmacists of Florida are most concerned about this bill. Pharmacists have said in surveys that they will not be able to provide the care they were trained to do and the public expects of them safely.

Therefore, SB 818 is bad health care policy and should definitely be defeated!

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Below you can see the Press Release regarding my announced testimony before the Florida Senate Health Policy Committee that was issued by the Florida Society of Health-System Pharmacists

We are excited to announce that a story on the Emily Jerry Foundation is featured in the Patient Safety awareness campaign publication distributed by Media Planet as an insert in the USA Today. The publication hit newsstands last Friday morning. Please remind your friends, family, customers, and colleagues in the New York, Washington D.C./Baltimore, Chicago, and San Francisco areas to pick up their copy of USA Today! The report can be found directly in the center fold.

Through USA Today, targeted events and conferences, and online/social media outlets (Facebook, Twitter, blog and website postings) the publication will reach more than 3 million readers, empowering them to take action, control of their health, and join our shared cause.

As you’ll notice, Friend of EJF, Flight Captain and American Hero Sully Sullenberger graces the cover of this great insert. We are incredibly proud to be associated with such a man. Hopefully one day the Emily Jerry Foundation will have saved countless lives through our daily work, just as Sully did that fateful morning. We salute him and patient safety advocates everywhere!

Now, for the moment you’ve all been waiting for! The full PDF can be downloaded or viewed below! Our feature article begins on page 10…

We had the opportunity to attend the premier of the Discovery Channel documentary “Surfing the Healthcare Tsunami; Bring Your Best Board” on Friday April 27th in Washington DC at the National Press Club. While there I met Sully Sullenberger who incredibly landed US Airways Flight 1549, which had been disabled by striking a flock of Canadian geese during their initial climb out, in the Hudson River off Manhattan, New York City, on January 15, 2009. All of the 155 passengers and crew aboard the aircraft survived. Sully is not only a great guy in my opinion, he’s a true American Hero!

This patient safety documentary features the initial interview I did last year with Eric Cropp, where I publicly forgave him for what happened with Emily. I have always felt very strongly about the fact that when these horrible tragedies occur in medicine, that the real focus should always be on “where did the system break down?’ and not on any one individual who clearly had no malice. In looking at things from this perspective, I truly believe that we can learn from these horrible events and implement measures and safeguards to prevent these same medical errors from occurring over and over again.

This documentary aired on The Discovery Channel for the first time Saturday, April 28th at 8:00am. It can be viewed below…

On March 1st 2006, my beautiful daughter, Emily, tragically died from a medication error during what was supposed to be her final round of chemotherapy. What makes Emily’s story even more heartbreaking is the simple fact that Emily had a very large yolk sack tumor in her abdomen that had completely disappeared after five short months of chemotherapy. The only reason she was receiving a final round of chemo was to make certain that there were no residual cancer cells remaining in her body that could cause her problems later in life.

After her tragic death, it was determined that the error that took Emily’s life was a direct result of an IV compounding mistake that had been made in the hospital pharmacy. Like most medical errors Emily’s death was really a direct result of “human error” that had occurred on the part of the pharmacy technician preparing Emily’s IV medication that day.

Shortly after establishing The Emily Jerry Foundation, I began focusing my advocacy efforts on trying to find solutions that would save lives through the “smart” implementation of technology to reduce this “human error” component that is all too prevalent in medicine. With that thought in mind I am very pleased to announce that one of our key patient safety technology partners, Codonics, with their Safe Label System, and The Emily Jerry Foundation are on a “Mission of Safety” during National Patient Safety Week this week. Please see our important press release located below.

Ever since the Emily Jerry Foundation was established a few short years ago, we began interacting and collaborating with great organizations like The Institute for Safe Medication Practices (ISMP), The American Society of Health System Pharmacists (ASHP), our technology partners like Codonics, SEA Medical, etc. The primary reason for this, was due to the fact that my beautiful daughter Emily died from a tragic medication error in 2006, as a direct result of “human error” that occurred when a pharmacy technician incorrectly compounded her IV medication that horrible day when she was overdosed. With that being said, ever since Emily’s death, I have been working very diligently to try to find, and clearly identify, logical ways in which our nation’s medical facilities could significantly reduce the probability of this “human error” component from arising during the course of a patient’s treatment. Bottom line, I wanted to find ways that made sense and would be cost effective for any medical facility to implement, regardless of their size and scope of treatment.

In 2011, at the American Society of Health Systems Pharmacists Midyear Meeting in New Orleans, I met a gentleman by the name of Robert Braverman for the first time. Robert is the President of a company called Medi-Dose which has been an industry leader for more than 30 years. They have an inexpensive system used by hospital pharmacies to package, handle, and dispense, predetermined amounts of medication, into individual unit doses for patients. Shortly after the meeting in 2011, Robert sent us a rather large box that included examples of all of their medication packaging and corresponding labeling. After receiving this from him, we began developing the overall idea for The Emily Jerry Foundation’s Guardian Angel Pediatric Safe Label Program.

Read More by clicking here…