On December third of last month, Michael Cohen, the President of the Institute for Safe Medication Practices (ISMP), Eric Cropp, and myself, had the opportunity to share Emily’s tragic story and the important lessons that have been learned from the medication error that took her life in 2006.
The day began with a wonderful keynote speech from former President Bill Clinton, titled “Embracing our Common Humanity”. During his speech President Clinton shared his philanthropic worldview and the very important humanitarian work that is being accomplished globally by the William J. Clinton Foundation. In my opinion, President Clinton’s speech was the perfect way to kick off the ASHP Midyear! As he was describing the inherent challenges of globalization, he really emphasized the growing interdependence, the people of the world now have on one another, as we all move forward into the future. He attributed this growing interdependence on the fact that much of the world’s population shares very similar goals and values. With that being said, as he spoke, I began drawing analogies to patient safety and quality of care in our nation’s medical facilities. The primary one being, just like many of the people of the world share the common goals and values President Clinton described in his speech, caregivers like physicians, nurses, pharmacists, pharmacy technicians, etc., also share many similar core values and common goals relating to patient safety overall.
Later that day, we gave our presentation before more than 2,500 people, entitled “The Emily Jerry Story: Lessons Learned From a Fatal Medication Error”. The reason I feel our presentation received a standing ovation is simply due to the fact that most of the audience was comprised of pharmacists from around the United States, who all share very similar values and exactly the same common goals when it comes to medication and patient safety. Bottom line, I believe every member of the audience was helping me honor my beautiful daughter Emily’s short life, by truly trying to learn from what happened to her and by ultimately finding ways to prevent similar tragedies from occurring to others. With all of this being said, I would like to genuinely thank everyone who attended and let them all know how sincerely grateful I am for their continued support of The Emily Jerry Foundation, as well as, for me personally.
Below are some high-resolution scans of the official program from the event. Click on the images to view them larger and/or download the files.
Last week I had the opportunity to speak at CareFusion’s Town Hall Meeting in San Diego which was a live webcast to all of their employees around the globe. This webcast was recorded and I should have a link to it soon. The following are a few of the comments we received on The Emily Jerry Foundation’s Facebook page shortly after the webcast:
“Hi, I work for CareFusion in Australia! I just heard you talk in a recording of our Town Hall Meeting. Thank you for sharing your story. I used to be a Peds Onc Nurse before I came to work at Alaris/CareFusion. The message you share is vital for everyone, all around the world. Thanks again!!!”
“Today..Emily’s dad spoke at our Town Hall.. about the medication error that led to her death… and how he is involved in making a difference in others’ lives… wow. What an amazing heart, to bring awareness to others, and to remind us that those who commit the error are also victims… wow..”
“Watched your video replay today from our CareFusion Townhall meeting. Thank you for your courage to pursue patient safety and your courage to tell your painful story. I know there are still many barriers to transparency and turning the Titanic, but with your help, we are another day closer. I am sorry for your loss of Emily and also the toll it took on your marriage and family. Praying God restores you and your family. You have a gift. Carry on and be strong. This world needs you to talk about medication errors.”
After the webcast Eric Cropp and I gave a lecture to the San Diego Patient Safety Council at CareFusion’s headquarters. Everything went extremely well!
We just received the following e-mail from Dr. Tim Vanderveen at CareFusion regarding our presentations the week before last in San Diego. I was very moved by it and wanted to share it with our supporters. Each and every presentation The Emily Jerry Foundation makes seems to leave a lasting imprint on the participants involved. We hope to continue to build momentum with great partners such as CareFusion.
Chris, Eric and Lisa,
On behalf of the 15,000 employees of CareFusion, I wanted to send you a note thanking you for participating in our Town Hall meeting. In addition to our San Diego based employees, your presentation on the tragedy of Emily’s death and the incredible efforts that your foundation is undertaking reminded all of our employees of why we do what we do as we focus on caregiver and patient safety. Just today as I was walking through our company cafeteria one of our maintenance staff stopped me to tell me how proud he was to work for a company that was focused on preventing the kind of errors that took Emily’s life.
I also want to pass on my thanks from our colleagues in the San Diego Patient Safety Council for the presentation by you and Eric. Again, nothing but positive feedback. I cannot imagine how difficult it must be for both you and Eric to stand in front of so many people who you never met, and most likely will never see again, but have the courage to share the intimate details of the tragedy, blame, forgiveness, and the unique partnership you have created. I suspect everyone hearing your stories could not imagine being able to do what you are doing if God forbid they were to experience a similar tragedy.
We all send our best wishes and applaud your work and sharing your unique and powerful example of making the world a better place.
Regards
Tim
As Emily’s father, had I known this one little detail…. Emily would still be here today!
Your babies, children, and loved ones are unknowingly being put at serious risk and could die exactly the same way Emily tragically died. Find out exactly what you can do today to keep your family and friends safe from these types of all too common medical errors. More importantly, we will show you ways that you can effectively protect them from dying from a similar senseless and horrific death!
Did you know that in 2012, six years after Emily died at the hands of a poorly trained pharmacy technician, and there are still five states with absolutely NO requirements for technicians who routinely compound IV medications on a daily basis? Furthermore, the individual state boards of pharmacy in these five states have no oversight, whatsoever, of pharmacy technicians in their respective states. With that being said, does it seem as though these state boards of pharmacy are really doing their primary job, which is to protect the residents of their states from unsafe pharmacy practice?
• New York
• Pennsylvania
• Michigan
• Colorado
• Washington DC
If you live in one of these states, or any state that loosely regulates pharmacy technicians, you can protect yourself and the ones you love immediately. Most people are not aware that it is well within your rights when you, or a loved one, go into any medical facility in our nation for treatment of any kind, to request that a registered pharmacist prepare, any and all, IV medications during the entire course of your stay! This is something you should always insist on prior to the treatment or procedure and it is imperative that you get this in writing from an administrator in authority at the facility where you or your children are being treated. As Emily’s father, had I known this one little detail, Emily would still be here today!
If you are truly as concerned as I am about this very important public safety issue, I would urge you to contact your state’s board of pharmacy, as well as, your state legislators immediately. In addition, please continue to visit the The Emily Jerry Foundation website (www.emilyjerryfoundation.org) for new and updated information regarding our new National Campaign for Improved Pharmacy Technician Training and Oversight that we look forward to introducing in the coming weeks. I am also pleased to say that this new campaign is a very important part of The Emily Jerry Pediatric Safe Patient Initiative that just began earlier this year.
The following is a great letter of recommendation we received from Washington State Patient Safety Coalition for the talk we gave in Seattle a few weeks ago. The Emily Jerry Foundation is proud to be associated with the WPSC and hopes to further our mutual vision of a more safe environment for patients around the country. Thank you so much for your support!
Click on the Image below to download a pdf of the letter.
Lisa and I had the chance to meet John J. Nance (keynote speaker for this event) last week at the premier of “Surfing The Healthcare Tsunami; Bring Your Best Board.” John is a great guy that is also featured in the documentary. We are very excited to take part in this opportunity to spread the message.
Last May, Dr. Charles Denham of TMIT brought Eric Cropp and I together for the very first time for an interview, since my daughter Emily’s tragic death. Emily died from a medication error that occurred only days after her second birthday in 2006. Shortly after establishing The Emily Jerry Foundation in 2009, I had explained to a number of people, including Dr. Denham, how and why I felt so strongly about publicly forgiving Eric for the death of my beautiful little girl Emily. Many people simply thought I had completely lost my mind and could not comprehend or understand why, as Emily’s father, I would ever want to take such a drastic step.
Dr. Denham has produced other very successful patient safety documentaries like “Chasing Zero”, narrated by Dennis Quaid. After discussing this particular issue of “forgiveness” at great length with him over the phone in 2010, he called me at the beginning of 2011, and proposed getting Eric and I together for what he referred to as a “healing moment”. This life changing interview will be featured in “Surfing the Healthcare Tsunami: Bring Your Best Board”. I will be attending the documentary premiere in Washington DC at the National Press Club next Friday April 27th. This film then airs for the first time the next morning on the Discovery Channel April 28th. It will also be aired May 5th, May 12th, and May 19th at 8:00 AM local time, however check listings in your time zone as some carriers vary in broadcast regions. You can read more about the premiere by visiting the SafetyLeaders.org website by clicking here.
The primary rationale for wanting to forgive Eric publicly for Emily’s death was simply due to the fact that, at no time did I ever feel he had any malice towards my daughter. Nor do I believe he ever meant my beautiful daughter any harm whatsoever. In fact, I have never felt that any one individual was responsible. It has always been quite the contrary. To this day, I truly believe that my little girl died as a result of two primary reasons. The first was due to a number of inherent systemic flaws that had existed in the pharmacy workflow that day that ultimately led up to the horrible error being made that tragically took my Emily’s life. Secondly, I truly believe that the Ohio State Pharmacy Board, at that time, should have really been held culpable in Emily’s death. The reason I say this is due to the simple fact that it was determined that a pharmacy technician had actually made the fatal error that had killed Emily. After the incident, the pharmacy technician had mentioned that she never really knew that highly concentrated sodium chloride (salt) could actually kill people. With that in mind, I have always asked myself why the Ohio State Pharmacy Board at that time, had absolutely no training requirements, licensing requirements, or oversight of pharmacy technicians in the state of Ohio? To make matters worse, they had to know that pharmacy technicians were being used on a daily basis at all of Ohio’s medical facilities to routinely compound IV medications going directly into patient’s circulatory systems. With that being said, I believe the Ohio State Pharmacy Board was really not doing their primary job, which was to protect the residents of their state from unsafe pharmacy practices. Bottom line, as Emily’s father, had I known that there would have been a very high likelihood, or probability, that a pharmacy technician who had little, to no, training would have been compounding my daughter’s IV medications, I never would have allowed it to happen. I would have insisted that only a registered pharmacist, with years and years of training, prepare all of Emily’s IV medications during the course of her treatment.
Special thanks to the Association for the Advancement of Medical Instrumentation (AAMI) for covering the Emily Jerry foundation in the April 2012 edition of AAMI News. We truly appreciate all their support in shedding light on our cause. An excerpt of the article is below:
Six years ago, Chris Jerry was going to surprise his 2-year-old daughter Emily with the best present she could ask for, which wasn’t a toy or even a pony. It was that she no longer had cancer.
But he never got to tell her.
On Feb. 26, 2006, Emily underwent one last chemotherapy treatment to eliminate residual cancer cells from the yolk sac tumor she had battled for six months, but something went terribly wrong.
When Jerry got to Rainbow Babies& Children’s Hospital in Cleveland, OH, that day, his daughter was already unconscious from an unbearable amount of pain.
“I just remember opening the door and my wife at the time had this look of horror on her face,” he told AAMI News.
I was interviewed after the Quality & Patient Safety fair at University Hospitals Case Medical Center by Cleveland’s News Channel 5 about the Emily Jerry Foundation and my speech to UH staff that afternoon. Watch the video footage below and click here to read the full story.
The Emily Jerry Foundation is determined to help make our nation’s, world renowned, medical facilities safer for everyone, beginning with our babies and children. We are accomplishing this very important objective by focusing on increasing public awareness of key patient safety related issues and identifying technology and best practices that are proven to minimize the “human error” component of medicine. Through our ongoing efforts The Emily Jerry Foundation is working hard to save lives every day.
Posted: January 29, 2013 by ejfadmin
New Article Highlights Medi-Dose, Inc. & Emily Jerry Foundation Partnership
Last Friday, I found out that The Emily Jerry Foundation’s Guardian Angel Pediatric Safe Label Program and our partnership with Medi-Dose had the following article appear in Surgical Products Magazine. It seems that our important new program is off to a very good start!