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Please read this great article about a talk given by Former President Bill Clinton at the Masimo Patient Safety Science and Technology Summit, this past January in Orange County, California. The underlying message and core philosophy in President Clinton’s speech mirrors mine exactly! Simply put, through the “smart” implementation of technology in medicine we really can ELIMINATE the 200,000 tragic deaths, like my beautiful daughter Emily’s, that occur every year as a result of preventable medical errors.

The main goal of the conference that former President Clinton took part in was to get manufacturers and developers of health monitoring devices to share information with one another in an effort to reduce unnecessary patient deaths in the United States. One of my favorite lines from his speech was as follows, “There need be no evildoers in this story. There’s just human nature and the nature of human development. Institutions have become ossified and rigid… where position is more important than purpose, or people get overwhelmed by complexity.” Because of this conference 8 major medical device manufacturers agreed to share data. This is a breakthrough we can all be excited about!

Read the whole story on the San Clemente Patch website by clicking here.

I came across a great article recently in the News-Herald, a small newspaper that serves Northeast Ohio. David Lynch, former mayor of Euclid, Ohio, wrote a touching piece on forgiveness and referenced my reunion and public forgiveness of Eric Cropp (the pharmacist responsible for Emily’s fatal dose), which can be viewed in the sidebar of our site. He holds me up as an example others can strive for when thinking of forgiveness in their own lives. I am humbled and honored to have touched him and inspired the article. Please read it when you get a chance by clicking on the scanned image below.

MEDIA RELEASE

FOR IMMEDIATE RELEASE
June 17th 2013

Media Contacts:
The Emily Jerry Foundation
Christopher S. Jerry
440-289-8662
[email protected]
www.emilyjerryfoundation.org

Traveling to New Mexico to Find out Why New Mexico State Pharmacy Board Member Was a “Driving Force” in Getting Pharmacy Technician Ratio Eliminated, Putting Tens of Thousands of Residents at Risk for Medication Errors!

CLEVELAND, OHIO- Last week, it was brought to my attention by a number of concerned pharmacists from the state of New Mexico that their state was now one of the few states in our nation to recently eliminate their pharmacy technician ratio mandate. If I understand correctly, under the new terms, the pharmacy technician ratio will now be determined by the pharmacist-in-charge (PIC). With this particular scenario, my primary concern from a patient safety standpoint is shared with many pharmacists themselves around the nation. It is NOT that the pharmacists themselves are not capable of making this very important determination. It’s quite the contrary, pharmacists are very qualified to determine safe ratios in their pharmacies. The primary concern, lies in the fact that in retail pharmacy especially, the large retail pharmacy chains treat their pharmacy workflow in their retail pharmacies too much as a volume based production line. If you live in New Mexico then you may want to take out health insurance with someone like New Mexico Insurance Services to protect yourself from these changes because with that type of mentality, through the corporate policies and procedures they implement, they put their core emphasis on quantity over quality, often at the expense of their customer’s safety. With that being said, my trepidation is due to the fact that pharmacy technician ratios are so closely tied to retail pharmacy’s PROFITS that the large retail pharmacy chains like Walgreens, CVS, Rite-Aid, etc., will now start to dictate and put pressure on their pharmacists in New Mexico to staff their pharmacies with as many pharmacy technicians as they so choose, throwing customer safety by the wayside, in an effort to maximize their profits. With that in mind, if a pharmacist employed by one of these large retail chains refuses to sign off on, or approve, a ratio in their pharmacy that they feel is clearly unsafe, the retail pharmacy will simply tell them to resign and find another job elsewhere.

As I have mentioned many times previously, the primary mission of any state board of pharmacy, is to protect the resident’s of their state from unsafe pharmacy practices. It is not clear to me how the New Mexico State Board of Pharmacy’s recent approval of the elimination of their pharmacy technician ratio will improve the safety, or benefit the residents of their state in any way, whatsoever. Again, the only people that stand to benefit from the elimination of the pharmacy technician ratio are the large retail pharmacy chains, as well as, the owners of the small independent retail pharmacies in New Mexico. They stand to benefit greatly by substantially increasing their PROFITS by now being able to legally staff their retail pharmacies with as many low cost, hourly, pharmacy technicians as they want, while simultaneously, lowering the number of registered pharmacists supervising and double checking these technicians work. Furthermore, by increasing the number of pharmacy technicians in any given pharmacy, you increase the overall number and volume of prescriptions that must be checked by the supervising pharmacist, thus, increasing the probability for “human error” and subsequent medication errors with catastrophic results. The following are just a few very relevant and well publicized pharmacy technician errors that really hit home with me, as I was lobbying in opposition of Senate Bill 818 in Florida earlier this year.

http://usatoday30.usatoday.com/money/industries/health/2008-02-12-pharmacy-errors_N.htm

http://abcnews.go.com/Blotter/walgreens-told-pay-285-mil-teen-pharmacy-%20%20%20techs/story?id=9977262#.UbyaxBaM_A0

As everyone is probably already aware, The Emily Jerry Foundation has been working very closely with several experts in safe pharmacy practice, the American Society for Health System Pharmacists (ASHP), the Institute of Safe Medication Practices (ISMP), and numerous state boards of pharmacy all over the United States, to keep the large retail pharmacy giants from lobbying to increase pharmacy technician ratios. Having worked so closely with these pharmacy professionals over the past few years, I have learned that the only reason the retail pharmacy chains lobby so hard to increase the ratios, or eliminate them entirely, is because it is in the best interest of improving their profits. When profit maximization strategies by retail pharmacy come at the expense of overall customer safety, I find it quite appalling!

What I found even more disturbing was learning that a New Mexico State Pharmacy Board member, Danny Cross, may have been a “driving force” behind the elimination of the pharmacy technician ratio in New Mexico. This is alarming, if true, given the potential conflict of interest, given that Mr. Cross is the owner of a retail pharmacy establishment called Southwest Pharmacy in Carlsbad, New Mexico.

I have made flight arrangements and will be departing for New Mexico on Wednesday, June 19th. During this trip, I have meetings scheduled with Larry Lorens, the Executive Director of the New Mexico State Pharmacy Board and will be attending their meeting on Thursday, June 20th, which I found it ironic that The Emily Jerry Foundation was already on their agenda (click here to see the agenda, particularly section 12c).

Also, during my trip, I hope to meet with the Governor, Susana Martinez, to discuss this very important issue and will also be trying to schedule a meeting with Danny Cross to discuss the underlying logic behind this ludicrous decision to eliminate the pharmacy technician ratio. I am extremely concerned about the safety of the residents of the state of New Mexico and will be doing everything I possibly can, with respect to my advocacy efforts and those of The Emily Jerry Foundation, to get their pharmacy technician ratios, not only reinstated, but lowered in their state.

After taking the fight to Florida only weeks ago over their harmful new proposed legislation SB 818 to increase the approved ratio of pharmacy technicians to licensed pharmacists, similar legislation is also under consideration in South Carolina. The South Carolina Pharmacy Practice Act if passed would increase the same ratio, as well as discontinue the current requirement for Live Continuing Education for pharmacists and pharmacy techs in that state. As you are all well aware, I am adamantly opposed to any type of such legislation and am attempting to wage a small war against these practices. I wrote the following letter to Senator Shane Martin of South Carolina’s 13th District. The stated goal and actionable practice of the Emily Jerry Foundation is to give each and every person we come in contact with respect and the benefit of the doubt upon first beginning a correspondence or personal relationship. Our purpose is to save lives, and we feel tactics that are too aggressive and hot-tempered mostly result in a lose-lose situation. My personal view is that the vast majority of politicians obviously care about the safety of their constituents or they wouldn’t have chosen public service as a way of life. That is why I am so urgently attempting to educate them, and hopefully help them realize that the policies they are pushing may actually be leading to more harm than good. Please help me get through to them! Contact your friends in the state of South Carolina and have them email or call their representatives today.

At the beginning of June, I was honored to give a keynote session at the annual AAMI 2013 Conference and Expo in Long Beach, titled “Changing the Culture of Medicine-A Father’s Powerful Message”. As I have mentioned many times before, ever since I began this journey as full-time patient safety/caregiver advocate and leader of The Emily Jerry Foundation, I have always strived with my talks and the foundation’s programming to be an active part of the overall “solution” to preventable medical errors. For that reason, I have always been a very strong proponent for “smart” implementation of technology in medicine as an effective way to significantly reduce the probability of “human error” in medicine. I must say though, it is positive to see more and more firms similar to Medtronic developing effective technology to help healthcare practices provide good care for their patients. When I first started the foundation based on this simple core premise, this is why I felt it was imperative, right from the start, that The Emily Jerry Foundation immediately establish solid partnerships and alliances with the key medical technology manufacturers like CareFusion, Codonics, MediDose, SEA Medical Systems, etc. By medical facilities around the nation putting into practice the systems and technology developed by organizations like these, I know for a fact, that many lives are ultimately being saved from tragic preventable medical errors.

Unfortunately though, these systems and vital technology can’t seem to be developed and implemented in our nation’s medical facilities, quickly enough, in my opinion. According to recent health care studies over 100,000 deaths occur in the United States from preventable medical errors every year, making preventable medical errors the third leading cause of death in the United States today. I find it astounding, that what this really means is that, unintentional preventable medical harm by caregivers, is only less deadly than cardiovascular disease and cancer!

Even in light of these very dismal statistics, what gives me such great hope and inspiration, in my day to day advocacy efforts across the nation, is that I know for a fact we have the capability to fix and address these issues and reduce the number of deaths and harm from preventable medical errors significantly. I also believe very strongly that one day we will completely eliminate them! I am so confident of this, simply due to the fact that, in my day to day work, I come into contact with so many amazing companies, like those aforementioned, and the brilliant individuals employed by them, that just like The Emily Jerry Foundation, are working so incredibly hard every single day to be active part of the SOLUTION. My genuine hope, is that all of the people I had the honor of meeting at the Association for the Advancement of Medical Instrumentation (AAMI) meeting in Long Beach, a few weeks ago, left my talk as inspired to continue their extremely important work in technology development, as they truly inspired me!

Christopher Jerry, President and CEO of the Emily Jerry Foundation, will address the AAMI 2013 Conference & Expo (June 1-3, in Long Beach, CA) on ways to change the culture of healthcare to reduce medical errors.

His presentation ties in well with the mission of AAMI, an alliance of more than 6,000 healthcare technology professionals dedicated to advancing the safe and beneficial use of medical technology. AAMI’s members work to improve medical device safety through the development and use of AAMI standards, professional certification, education, summits and other technical resources.

AAMI 2013 will include a full program of educational sessions devoted to patient safety, addressing such critical issues as human factors, electronic medical records, power-strip misuse, sterile processing, alarm fatigue, and much more. Full details about the conference are at www.aami.org/ac.

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. It is no wonder that people are using online pharmacies for their medication, for example, and so on. It provides the service they need in a more efficient way.

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. They do this by investing in the best quality equipment and highly trained staff. For example, when they consider looking for effective centrifuges they would go to a company like SciQuip, making sure that the equipment performed to a high stdard rather than opting for a cheaper option just to increase their 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.

***

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

—

Hi Mr. Jerry,

I am pharmacist with Kroger in Cincinnati, and had the opportunity to hear you speak at Paul Brown on Wednesday. I really wanted to come and chat with you after the program, and let you know the impact you had on me personally, but never felt like I could hold it together to talk to you without tears running down my face.

I have never been so affected professionally as I was after listening to your program. I am the mommy of four young kiddos, two of which are beautiful little two year old girls, just like Emily. So, you can imagine that the impact of what happened to Emily really hit close to home for me. I always knew that becoming a mom would make me a better pharmacist, but that statement has never been more accurate, after listening to your testimony. I really don’t have the right words to say to you, but to let you know that you really, really are making a difference by sharing your story. I will never forget you, Emily, or the impact you have had on me personally and professionally.

With that being said, is there any way that I can get a copy of the video you showed at the beginning of your talk, to share with my staff pharmacist and technicians? I feel like from time to time, everyone gets careless, and I would like to remind them how important they are in making sure our customers are safe.

Again, I can’t thank you enough for reminding me of the role I have as a pharmacist each and every day.

Thank you,
Nicole Cogan

—

Chris-

I am a Kroger pharmacist that you spoke to just a few days ago. I am the one who showed you a picture of my daughter, Chloe, who looks so similar to Emily. I wanted you to know that I truly admire the work you are doing to improve patient safety. If there is any thing I can assist with please feel free to contact me.

Thank you for sharing your tragic story so that there may be saved.

Lauren Gantzer

—

Mr. Jerry,

I had to send you a note to let you know how touched I was by your presentation yesterday at the Pharmacy Show. As a mother and a grandmother myself, I can’t imagine going through what you went through. I met you at the breakfast portion before the pharmacy show started and you gave me your card. I had no idea who you were. Working as a pharmacy technician, I of course have heard about Emily’s story, but I never knew the whole story. I don’t think you left too many dry eyes in the place yesterday. This year is the first year that Kroger has let technicians go to the show and I know the one thing that will stay with me from this is your story and precious Emily’s beautiful face. My heart goes out to you for your forgiveness for the parties involved. Emily is in heaven cheering for her Daddy for carrying on the work that she started.

God bless you for all your hard work and getting your story out there. You had an effect on alot of people yesterday.

You will see your beautiful daughter again someday when God feels your job is done. Emily will be saving a place for you in heaven.

Take care,

Kim Clark

—

Hi Mr. Jerry

My name is Nick Woodward and I am the lead pharmacy technician at the Kroger Pharmacy on Mall Road in Florence, Kentucky. I was at your presentation today at Paul Brown Stadium. Your presentation really moved me and hit home for me. I have a 20 month old little girl. First let me say I am sorry for your loss and I am amazed by your forgiveness and strength. You inspired me today. I want you to know I’m going to share everything you said today with all my pharmacy technicians and any other technicians I talk to through out the day. I was also disappointed that the Kentucky score card was a D. I would like to know what I can do or what we can do to get that score higher. I would like to help any way I can. Thank you for having the courage and strength to talk to us today. And thank you for making our pharmacy a safer place. Once again I am sorry for your loss.

Sincerely
Nick Woodward

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“Chris, your work is so important and I’m incredibly grateful for the folks at Kroger for encouraging you and reminding you of that fact. We need you.”
~Richard M. Edwards via Facebook

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“@JMcDeez: @EmilyJerry Cannot thank you enough for speaking w/our team yesterday. They were still talking about your inspiring message today. #Awesome”
~Jaime McDermott via Twitter

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.