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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.

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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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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

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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

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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

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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.

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: bean.aaron.web@flsenate.gov

Jeff Brandes
R-22nd District
St. Petersburg
District Phone: (727) 552-2745
Tallahassee Phone: (850) 487-5022
Email: brandes.jeff.web@flsenate.gov

Oscar Braynon
D-36th District
Miami Gardens
District Phone: (305) 654-7150
Tallahassee Phone: (850) 487-5036
Email: braynon.oscar.web@flsenate.gov

Anitere Flores
R-37th District
Miami
District Phone: (305) 270-6550
Tallahassee Phone: (850) 487-5037
Email: flores.anitere.web@flsenate.gov

Bill Galvano
R-26th District
Bradenton
District Phone: (941) 741-3401
Tallahassee Phone: (850) 487-5026
Email: galvano.bill.web@flsenate.gov

Rene Garcia
R-38th District
Hialeah
District Phone: (305) 364-3100
Tallahassee Phone: (850) 487-5038
Email: garcia.rene.web@flsenate.gov

Denise Grimsley
R-21st District
Sebring
District Phone: (863) 386-6016
Tallahassee Phone: (850) 487-5021
Email: grimsley.denise.web@flsenate.gov

Arthenia Joyner
D-19th District
Tampa
District Phone: (813) 233-4277
Tallahassee Phone: (850) 487-5019
Email: joyner.arthenia.web@flsenate.gov

Eleanor Sobel
D-33rd District
Hollywood
District Phone: (954) 924-3693
Tallahassee Phone: (850) 487-5033
Email: sobel.eleanor.web@flsenate.gov

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…