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Twenty years ago, I lost my daughter Emily to a preventable medication error.

The week before last, I stood on Kiawah Island delivering the keynote at the South Carolina Society of Health-System Pharmacists (SCSHP) 2026 Annual Meeting…surrounded by clinicians who have dedicated their lives to making sure tragedies like hers don’t happen again.

That’s something I don’t think I’ll ever stop pausing to reflect on, because this work was never part of the plan.

And yet, over the past 17 years, I’ve been given the extraordinary privilege of walking alongside a community of clinician caregivers who refuse to accept preventable harm as inevitable. What I’ve come to realize is something incredibly powerful and encouraging…I’m not alone in this work.

All the healthcare professionals I met at SCSHP embody that in every sense. These are not just experts in their field—they are people who feel a deep sense of responsibility for the safety of every single patient they serve. People who are actively redesigning systems, strengthening processes, and building safeguards so that human error never reaches the bedside.

And what continues to inspire me, every single time, is this:
They are just as passionate about this mission as I am.

Over the years, I’ve had the opportunity to see Emily’s legacy take shape in ways I never could have imagined, in classrooms, in legislation, in safety initiatives, and in the hearts and minds of clinicians across the country.

Moments like this past week are a powerful reminder of that.
Her story is no longer just my story…it lives on through all of you.
-Through your work.
-Through your commitment.
-Through the lives you protect every single day.

To the entire SCSHP community, thank you…not just for the opportunity to speak, but for the work you do day in and day out to strengthen systems, improve care, and prevent the preventable.

I am so incredibly grateful to be on this journey with you!

Together, we are turning tragedy into purpose, saving countless lives in the process…and moving closer and closer to zero preventable harm.

Last week I had the honor of delivering the opening keynote at the Pacific Coast Patient Safety Conference in beautiful Monterey, California, hosted by the California Society of Health – System Pharmacists and Chapman University School of Pharmacy.

Each time I’m invited to speak at events like this, I’m reminded how deeply meaningful this journey has become.

Sharing Emily’s story during my presentation, “From Tragedy to Triumph: Mitigating the Risk of Human Error to Save Lives,” is never easy. But being in a room filled with clinician caregivers who dedicate their lives to protecting patients, ensuring the best possible outcomes, and improving medication safety makes these moments incredibly powerful.

Seventeen years ago, after the loss of my daughter Emily due to a preventable medication error, I could never have imagined that this would become my life’s work. Yet through the Emily Jerry Foundation, I’ve been given the profound privilege of collaborating with some of the most dedicated clinician caregivers in healthcare…people who show up every day with a shared commitment to one simple goal: preventing the preventable.

I was also honored to participate in a Regulatory Panel discussion with Anne Sodergren from the California Board of Pharmacy and Rita Jew from the Institute for Safe Medication Practices (ISMP). Conversations about how regulation, culture, and system design intersect are essential as we continue working toward safer healthcare.

My sincere thanks to the California Society of Health – System Pharmacists, Chapman University School of Pharmacy, and everyone who helped make this conference such a meaningful experience.

If sharing Emily’s story helps even one clinician pause, rethink a process, or strengthen a safety system, then her legacy continues…moving us one step closer to preventing tragedies like hers from ever happening again.

Preventing the preventable! Patient safety is a responsibility we all share on every level!

The week before last truly meant a great deal to me. I was honored to be invited back to Touro College of Pharmacy to deliver another Dean’s Hour lecture, after having the privilege of speaking there last April.

Spending time with PharmD students and faculty in this setting is always deeply humbling. These students aren’t simply earning a degree, they are preparing to assume an enormous responsibility as future leaders in medication safety. Very soon, patients and families will place their trust in them during some of the most vulnerable moments of their lives.

When I share Emily’s story and the lessons learned from it, my hope is never to instill fear. It’s to help students understand the very human side of healthcare…to recognize that we all become patients at some point, as do the people we love, and that medication safety must be intentionally designed into every system, process, and decision they make.

What stood out during this Dean’s Hour was the thoughtfulness with which these students engaged. Their questions reflected not just curiosity, but true ownership of the responsibility they are preparing to carry.

That’s what gives me real hope!

I’m incredibly grateful to my friend, Batoul Senhaji-Tomza, PharmD, MPH, for welcoming me back and for her continued commitment to shaping pharmacists who understand that preventing harm is not optional, it is foundational to their profession.

Every time I speak with pharmacy students, I leave encouraged. They are our future leaders in medication safety, and Emily’s legacy will live on through the patients they protect and the systems they improve.

I’m really looking forward to heading to New York City this morning for two very meaningful speaking engagements at Touro University’s College of Pharmacy.

This journey began with an invitation to deliver a CE presentation at the NYCSHP Winter Exhibit, which is an annual professional gathering hosted by the New York City chapter of the New York State Council of Health-System Pharmacists. I’m deeply grateful to Marina Barsoum, PharmD, BCOP, President of NYCSHP, and Tamara Oz (Hernandez), President-Elect, for reaching out and giving me this wonderful opportunity. This event brings together pharmacists, pharmacy technicians, student pharmacists, and health-system professionals with a shared commitment to learning, collaboration, and, most importantly, improving medication safety.

Once the faculty at Touro University’s College of Pharmacy learned I would already be on their Times Square campus, they asked if I would also be willing to provide a Dean’s Hour lecture for their P1 PharmD students. I didn’t hesitate
for a second. I’m especially thankful to my friend Batoul Senhaji-Tomza, PharmD, MPH, who is an Associate Dean and Professor at Touro, for inviting me back once again. Being welcomed to lecture to their students for a second year is truly an honor.

I feel incredibly privileged to spend time with our future healthcare leaders and
to continue sharing Emily’s story and the lessons learned through the work of
the Emily Jerry Foundation. Opportunities like these just reinforce why this mission matters so deeply: modifying core systems, processes, and protocols to reduce the risk of human error, working together to prevent the preventable, and ultimately saving countless lives.

Grateful to Touro University’s College of Pharmacy, NYCSHP, and to all the dedicated clinician-caregivers committed to advancing medication safety and moving us closer and closer to zero preventable harm.

I was very grateful for the opportunity to speak at the RWJBH Clara Maass Medical Center Leadership Retreat at Glen Ridge Country Club in New Jersey the week before last. Sharing Emily’s story, and the valuable lessons learned from her tragic and preventable medication error is never easy, but it remains the work I feel profoundly called to do.

There was something especially fitting about doing this work with an institution named after Clara Maass. A nurse whose legacy embodies extraordinary courage and selflessness, Clara volunteered in 1901 for medical research aimed at better understanding yellow fever, ultimately giving her life in service to advancing patient care and saving others. Her story is a powerful reminder that healthcare has always demanded bravery, humility, and an unwavering commitment to learning to improve patient care and prevent harm.

For more than 16 years, my work with the Emily Jerry Foundation has been guided by a simple truth: safer care is not achieved through individual vigilance alone, but through strong systems and committed leadership. I am continually inspired by frontline clinicians, the pharmacists, nurses, physicians, and technicians, who dedicate themselves every day to protecting patients, saving lives, and improving the quality of lives of people diagnosed with all kinds of various chronic disease states. Equally critical is the role of healthcare executives and system leaders who really understand that safety begins at the top. Culture, resources, and thoughtful system design are not optional; they are absolutely essential.

What stood out during this retreat was the shared recognition that while human error is inevitable, harm is not. When organizations truly invest in building highly reliable systems focused on safety, that support learning, transparency, and accountability, real and sustainable change becomes possible.

I am deeply grateful to the Clara Maass leadership team for their openness, engagement, and commitment to advancing a true culture of safety. Through partnerships like these, Emily’s legacy continues to live on, making a huge difference that is ultimately helping to save countless lives.

I was truly honored to represent the Emily Jerry Foundation last week at Mount Sinai Health System, where I had the privilege of delivering the keynote address to kick off their Medication Safety Together – An Interdisciplinary Summit for Shared Learning and Safer Systems. It was an extraordinary day, one I will remember for a very long time.

What made this presentation so meaningful for me wasn’t just the summit itself, it was the incredibly heartfelt response from the clinicians in attendance. Receiving a standing ovation for Emily’s story, and for the work I’ve been doing so passionately in medication safety for more than 16 years, was profoundly humbling. One nurse kindly shared, “There were no dry eyes in the room for our dear Emily.” Hearing dedicated caregivers refer to my beautiful daughter as “our dear Emily” touches me more than I can express. I often remind the healthcare teams I work with that the guardian angel in the EJF logo, designed in Emily’s likeness, wasn’t chosen because I see her only as my guardian angel… she is theirs as well.

Moments like this remind me of the very unconventional path I’ve been on since 2006, when I lost my beautiful daughter to a tragic and preventable medication error on what should have been her last day of treatment. It’s a path I never would have chosen, but one that God has continued to guide with purpose. Through Emily’s legacy, He has opened doors to work alongside remarkable clinicians, educators, and healthcare leaders across the country, all striving toward the same shared mission of zero preventable harm.

What struck me most at Mount Sinai was the deep commitment their entire team has to fostering a true culture of safety. The thoughtful posts shared afterward by leaders across the system, expressing their dedication to transparency, learning, and supporting their teams, were all incredibly inspiring. Their passion for improving systems, processes, and protocols, aligned perfectly with everything the Emily Jerry Foundation advocates for.

A heartfelt thank you to the outstanding team at Mount Sinai who made this summit such a tremendous success. People like, Joe Pinto, Beth Oliver, David Reich, Mackenzy Scott,MBA,RN, Kim Zammit, Isabella Royes, Simone Muller, and so many others whose hard work and vision made this event possible.

I genuinely look forward to continuing this life saving work together improving medication safety and preventing the preventable!

During this giving season, please consider making a charitable contribution to support our mission to improve medication safety!
Donate today at: https://emilyjerryfoundation.org/donate/

What began with unspeakable heartbreak after Emily’s preventable medication error has grown into a lifelong mission: ensuring no other patient or family ever endures a similar tragedy.

Over the past 16+ years, I’ve had the privilege and the immense blessing of working alongside incredible clinician leaders, educators, and industry innovators to advance safer systems, strengthen processes, and inspire the next generation of healthcare professionals who share the same passion for preventing the preventable.

When the Emily Jerry Foundation launched the National Pharmacy Technician Initiative and Interactive Scorecard in 2013, our goal was simple yet ambitious: to raise awareness and drive reform in how pharmacy technicians are trained, certified, and overseen across the U.S.

This interactive map (located near the bottom of our homepage if you scroll down a bit at https://emilyjerryfoundation.org/), developed by EJF and powered by the American Society of Health-System Pharmacists (ASHP), was designed to highlight disparities among states and promote stronger, safer standards for IV medication preparation in hospitals and health systems nationwide.

Today, I’m proud to share that our 2025 update marks another major step
forward:
✅ 17 states improved their overall scores this year.
✅ In 2013, five states had a “0” score—no oversight of pharmacy technicians. Today, we’re down to just one.
✅ 22 states now earn a “B” score or higher, compared to just 13 in 2013.

This progress reflects more than a decade of collaboration and shared commitment to patient safety. It shows what’s possible when foundations, clinician caregiver experts, healthcare organizations, regulators, and policymakers unite to drive lasting change.

A sincere thank-you to Douglas Scheckelhoff and his outstanding team at ASHP for their partnership, data, and dedication to fairness and transparency, each vital to this initiative’s success.

Looking ahead, I’m excited to continue collaborating with the ASHP state
affiliates who recognize the vital importance of having well-educated,
career-oriented pharmacy technicians on their teams to ensure medication safety. The Emily Jerry Foundation and I personally stand ready to support and collaborate in any way possible to advance technician oversight and these vital medication safety initiatives.

Let’s keep fighting the good fight and keep this positive momentum moving forward…until one day, our nation achieves straight “A”s across the board!

A few years after launching the Emily Jerry Foundation’s National Pharmacy Technician Initiative and Interactive Scorecard, introduced in partnership with ASHP in 2013, I had the honor of speaking at the Northland Association of Pharmacy Technicians Annual Fall Conference in Fargo, ND. Back in 2015, I was thrilled to present at this important event, knowing that North Dakota was the only state to receive a perfect score from ASHP ’s team of experts. That’s why it was such a privilege to be invited back ten years later to deliver two CE presentations the week before last, including the keynote, at this year’s 32nd Annual Fall Conference, appropriately themed “Medication Safety: Fitting the Pharmaceutical Care Team Together Piece by Piece.”

From the very start of the conference, I was touched and pleasantly surprised to see that every attendee received a crocheted “positive pill” holding a small banner that read: “Every medication you touch: Makes a difference,” alongside a picture of my beautiful daughter, Emily. It was such a meaningful reminder of exactly why the pharmacy team does this important work, and of Emily’s lasting legacy, which continues to inspire so many around the globe…ultimately saving countless lives!

Pharmacy technicians play such a vital role in ensuring safe medication use. My longtime mentor, Mike Cohen from the Institute for Safe Medication Practices (ISMP), once told me: “Chris, there’s not a pharmacy on the planet that can operate safely without well-educated, career-oriented pharmacy technicians.” I couldn’t agree more.

My friend Diane Halvorson, RPhTech, CPhT-Adv, CSPT, embodies exactly that standard of excellence. From serving two consecutive terms as President of the North Dakota State Board of Pharmacy, to becoming the first pharmacy technician elected to the NABP Executive Committee, to being nationally recognized as the Pharmacy Technician Certification Board (PTCB)’s Certified Pharmacy Technician of the Year—throughout her career, Diane has led by example, elevating the profession while always keeping medication safety the absolute top priority.

I extend my deep appreciation to Diane and her team for the warm welcome and for their unwavering commitment to advancing the pharmacy technician profession and protecting patients.

Last week in Fargo, on behalf of the Emily Jerry Foundation, I had the privilege of speaking at the Northland Association of Pharmacy Technicians (NAPT) 32nd Annual Fall Conference and was also honored to be invited to lecture again at the North Dakota State University‘s College of Health and Human Sciences. The auditorium was filled with interprofessional students, primarily future pharmacists and nurses, who listened with attentiveness and engaged with a real sense of purpose.

As was the case with this presentation, I’m always so grateful to be invited back to speak to the next generation of future leaders in healthcare and was deeply humbled and inspired by their overall energy. These young professionals will soon step into roles where every decision they make will directly affect patients’ lives. What makes moments like this so meaningful is my unwavering belief that their leadership, compassion, and dedication will be pivotal in preventing medication errors, advancing patient safety, and driving the lasting changes in healthcare that we are all striving for…changes that will ultimately end up saving countless lives!

As I often remind students during my lectures, the guardian angel logo of the Emily Jerry Foundation, modeled after my beautiful daughter, Emily, isn’t there solely because I believe she is my guardian angel (though I know she is). She is their guardian angel too, representing the human side of their future careers in healthcare. We are all patients at some point in our lives, as are our loved ones. Keeping this human side of healthcare at the center of everything they do on a day-to-day basis, always striving to provide the best possible care for every single one of their patients, will surely make all the difference throughout their entire careers.

For me, these experiences are deeply personal. I share Emily’s story not only to honor her memory but also to shed light on the human cost of medical error. Emily’s life was tragically cut short in 2006 by a preventable medication error, one instance of a far broader issue that unfortunately claims hundreds of thousands of lives every year in the U.S. These tragedies are not inevitable. They are preventable. And preventable means they simply do not have to happen.

A heartfelt thank you to Dr. Heidi Eukel, Professor of Pharmacy Practice at NDSU, for inviting me and making this event possible. I am profoundly grateful to their entire staff and students, for the warm welcome and for embracing the importance of this vital conversation.