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A great heartfelt article was recently written by Michael Cohen, President of the Institute for Safe Medication Practices (ISMP), a non-profit healthcare organization that operates the voluntary and confidential ISMP Medication Error Reporting Program. I am very proud to be affiliated with their organization. Together we can truly change things for the better…

A dad embraces the pharmacist responsible for his daughter’s death
MONDAY, NOVEMBER 14, 2011

Emily Jerry was just two years old when she died from a medication error made by a hospital pharmacy technician in Cleveland. She had undergone surgeries and four rounds of chemotherapy to treat what doctors said was a highly curable malignant tumor at the base of her spine.

According to her parents, Emily’s previous treatments had been so successful that her last MRI showed that the tumor had miraculously disappeared. This last treatment on her second birthday was just to be sure that there were no traces of cancer left inside of her. Tragically, the technician mixed her final dose of chemotherapy improperly, in a saline solution that was 23 times more concentrated than it should have been.

Read more…

Jail time, loss of licensure questioned

by Karen Blum

More than three decades later, Dennis Tribble, PharmD, is still haunted by the memory of one of the worst cases of his professional life. Now the chief pharmacy officer for Baxa Corporation, Dr. Tribble was at that time a pharmacist in a hospital he prefers not to name.

“I had been practicing for a number of years by that time. I failed to note that an adult dose of quinine had been prescribed for a pair of 10-year-old twins suffering from malaria. It put those kids into heart block and almost killed them,” said Dr. Tribble, his voice shaking.

What support did his hospital provide? “One of my bosses sat down with me and said, ‘I think you’ve already beat yourself up a whole lot more on this than I’m going to. You’re going to be a lot more careful, right?’ That was the extent of the counseling I got,” Dr. Tribble recalled. “To this day I look back on that incident in terror. I was functionally at less than half speed for about two weeks after that. I second-guessed every move I made. When this kind of thing happens, you don’t believe in yourself or in the quality of anything you do.”

Read more…

A strong patient safety advocate and great guy, Dennis Tribble of Baxa recently posted a moving blog about the Emily Jerry Foundation on the American Society of Health System Pharmacists website. I am very thankful for his efforts in continuing to promote our cause and giving the foundation a larger platform in order to reach many more people. I have copied an excerpt below which I think you’ll enjoy. A link to the full post follows…

A painful experience…
Created By: Tribble, Dennis On Wed, Oct 05, 2011 09:16 AM

I just did something that may be the bravest thing I ever did, or the stupidest… I relived my experience as the maker of a medication error in an article that will be published in Pharmacy Practice News. It’s amazing how clear that memory is, how immediate it is, and how it still affects me emotionally even just to talk about it. That memory is 31 years old.

I think I got started down this road as a result of spending the morning with Chris Jerry. If that name doesn’t ring a bell, he is the father of Emily Jerry, the little girl who died as the result of a tragic medication error in which 23.4% Sodium Chloride rather than 0.9% Sodium Chloride was used to reconstitute what would have been her very last, “just in case” dose of chemotherapy. Chris tells me that the radiological images showing her progress were just incredible; they had only decided to do this dose “to be certain there were no lingering cancer cells”.

Chris talked about Eric Cropp, who he has publicly forgiven, and with whom he speaks publicly about the importance of systems thinking in error prevention, as well as about the need for consideration for what Albert Wu has described as “the second victim” of a serious medical error, the healthcare provider who commits the error.

Talking about his experience brought me clearly back to the day that I learned that I had sacrificed care to the god of productivity, and very nearly killed two children. It is a mistake I never made again, but I was seriously impaired for several weeks after that.

Read the full blog post by clicking here.

I’m genuinely looking forward to giving my patient safety lecture to the accomplished staff of Union Hospital in Dover, Ohio next Wednesday morning, October 19th. The Emily Jerry Foundation is extremely proud and honored to work with medical facilities across the nation like Union Hospital. They are recognized among the top 5% of around 5,000 short-term, acute-care hospitals in the United States and have received both the HealthGrades 2011 Patient Safety Excellence Award, as well as, the 2011 Emergency Medicine Excellence Award.

Click here to learn more about Union Hospitals HealthGrades awards.

Below are some comments we received from attendees to our webinar that took place the morning of October 5, 2011. It seems we are truly making an impact with these presentations. I am very thankful for the opportunity, as well as for all those who took part in the event that provided feedback – both positive and negative. The positive feedback reinforces my drive to spread the message, while negative feedback usually provides constructive criticism which can be used to present a better and more effective delivery in the future. Thank You once again to PharmCon!

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It’s difficult when the law is one way but the employer choses to ignore the law because the “front line” is who gets in trouble, not the “desk jockeys”. Certification may be mandated, but that’s not necessarily what you get.

I wasn’t sure what to expect from this presentation but I thought the topic was very interesting. I think it was very well done and it’s great that Mr Jerry was able to participate and that there was info on the foundation and Second victims.

Great presentation.

Again, thank you for the enlightening presentation of Fate, Destiny: Life I am awakened to the power of patient safety, responsibility and personal healing. The sharing of those involved brought a smile to my face and a dance within my soul. Thank you.

Tragic situation for all parties involved. Shouldn’t the OH State Board of Pharmacy had some responsibility as well in the fact they did notm, at the time of the incident, regulate pharmacy technician?

n/a

I think Eric Cropp was treated rather badley it was an error that any one could have done, the tech here was not focused on what she was doing also concentrated solutuons should be kept away from IV preperation areas seperated bins locked. The days we all come home from work with no errors are the best days

I saw the original webinar also. Wow, what a powerful, emotional story. Thanks!

N/A

Best presentation in all respects that I have seen. Thank you.

Nice follow up to the other CE

Excellent program

2 ce programs please

Seemed very biased towards the pharmacist.

A Pharmacist must learn to prioritize tasks and not allow themselves to be rushed. Put a person with the name and think about the condition(s) being treated and how an error could affect the patient and family. If an error is made take ownership and responsibility for it and offer sincere apology for any potential negative outcome(s).

a sad and emotional situation for all involved

Very good presentation

great presentation

This is a very powerful story. It made me cry..

wow, how sobering

thank you

Very important topic medication error and the end results.

This is a story that needed to be told. Very informative and inspiring.

Excellent presentation!

excellent webinar !! It had a lot of information to think about!!

Its all about focus, staying aware that what we do isn’t just a list of tasks but a person at the receiving end of our work. Over worked and under staffing is becoming a broader issue and projects errors such as this horrific one.

This could have been avoided if basic safety procedures were instituted as policy in the hospital & followed to the letter.

This was one of the best CE’s I have ever participated in, and certainly the first time a CE has brought me to tears. The gravity of what we as pharmacists do everyday is huge, and we can not forget the human element of our job. Thank you so much for presenting this moving and informative CE. God bless Mr Jerry and Eric, as you will both be in my prayers.

this should be mandatory for every health care provider

I CAN SAY GOOD EXAMPLE OF REAL LIFE CE- MED ERRORS,

This was a wonderful CE. Thank you very much for putting everything you have out there to educate as on something that we have the potential of dealing with.

this is a very eye opening lesson that if we do not Love God above all, we can be doomed to such tragedy, that will humble us, for Eric, he loved his profession so much more than God. Mr Jerry’s Family was given the hardest test, but thank God he learned to forgive. They are characters in the story so we may all learn.

na

Excellent presentation- we all needed the reminder

Very moving! Thank you

My thanks to Mr. Cropp and Mr. Jerry for sharing such a painful time in both their lives. Their willingness to do so may protect many, many “Emilys” in the future.

A nearly identical error happened at our hospital in north carolina. Thank goodness the pharmacist, one of our best, did not go through anything comparable. The board just focused on making sure the hospital put into place systems that would prevent another error. We are still understaffed, though.

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I had the opportunity to tell Emily’s story to a great group of people at the Baxa Corporation. They are involved in designing and manufacturing technology that will truly change lives for the better. I can’t stress enough how thankful I am to them all. As a patient safety advocate I recognize that these are the people who are saving countless lives every single day. I truly appreciate the opportunity to visit their offices, and am excited about our relationship going forward. Check out the video of my speech below..

For Immediate Release

September 22, 2011

Patient-Safety Advocate Baxa Corporation Joins Forces with the Emily Jerry Foundation to Champion Pharmacy Safety Education and Legislation

Englewood, Colo. – “Fatal saline overdose.” Three words a parent never expects to hear. But Chris Jerry did. Jerry’s daughter Emily died when a pharmacy technician’s mistake resulted in a fatal dose of saline solution. Three years later, in 2009, Jerry founded the Emily Jerry Foundation, a non-profit foundation dedicated to the prevention of medical errors. Today, patient-safety advocate Baxa Corporation formally joins forces with the Emily Jerry Foundation to evangelize patient safety.

As an Emily Jerry Foundation partner, Baxa will collaborate with Chris Jerry, Foundation President and CEO, to increase public awareness of solutions that can reduce the rate of human errors. The Baxa pharmacy workflow management tool, DoseEdge®, through barcode verification of every drug ingredient, has prevented more than 339,500 dose preparation errors in US hospital pharmacies.

“The Emily Jerry Foundation’s mission of improving pharmacy safety and reducing the rate of human error matches the vision my father had over three decades ago when he founded Baxa,” commented Baxa CEO Greg Baldwin. “Every day the Baxa team works to develop innovative pharmacy technologies for safe medication handling and delivery. We embrace the opportunity to join forces with the Emily Jerry Foundation, to increase public awareness of automation technologies that can improve dose safety and save lives.”

Read the entire official Baxa News release about the Emily Jerry Foundation partnership by clicking here.

The Emily Jerry Foundation is very proud to announce the new partnership with Baxa Corporation. I have been working extremely hard to establish key partnerships with like minded individuals, organizations, and patient safety oriented technology manufacturers across the country like Baxa. Patient safety is a number one priority for the people at Baxa. Through the implementation of Baxa’s technology and products into the pharmacy workflow,  medical facilities across the nation can now significantly reduce the human-error component of medicine that can often lead to medication errors and similar tragedies like Emily’s. With that in mind, The Emily Jerry Foundation is genuinely looking forward to a very long and mutually beneficial relationship between our organizations.

I am looking forward to visiting Baxa Corporation this month to give presentations and to meet their team in Englewood Colorado. Additionally, I am scheduled to do a Satellite Symposium with Dennis Tribble, Baxa’s Chief Pharmacy Officer and Chief Technology officer, at the upcoming American Society of Health-System Pharmacists (ASHP) Midyear Clinical Meeting in New Orleans this December.

*****

About Baxa Corporation

Baxa Corporation is honored to partner with the Emily Jerry Foundation. Baxa is a leading provider of innovative, solution-based technologies for delivering safe patient doses, especially intravenous doses. Its systems and devices promote the safe and efficient preparation, handling, packaging and administration of fluid medications.

Baxa offers the DoseEdge(r) Pharmacy Work Flow Manager, a software system intended to ensure that compounded IV doses contain all the right ingredients in the right amounts. Additional products automate the preparation of syringe-based doses as well as IV nutrition doses (TPN). Baxa Corporation is also a pioneer in the use of oral syringes for accurate measurement and safe delivery of oral liquid medications to neonates, children and older adults.

Additionally, Baxa supports continuing education for pharmacists and healthcare professionals at our STAR Center(r) (Skills Training Academics and Resources) training facility, as well as offering a complimentary educational webinar series.

For more information about Baxa Corporation visit us online at www.baxa.com.

Last Week, I had the pleasure of performing another Continuing Education webinar with PharmCon. To view the webinar click on this link for FreeCe.com. The following are a list of comments and feedback we received on the event. Lots of great feedback and kind comments. I truly appreciate all the acknowledgements and am excited my story is helping to make a difference!

The following are results from a post-webinar survey…

– 84% of participants rated the Webinar Excellent overall
– 84% of participants rated the content Excellent
– 78% of participants rated the content to be Educational vs. Commercially biased
– 70% of participants thought it was rational to pass Emily’s Act in Ohio
– 68% of participants thought Emily’s Act had  a positive impact on Pharmacy Techs

Here are some raw comments from participants in the web chat after the webinar was completed:

alexplee : thank you…
louielou2002 : Thank you!!!
jets1fan : Best and most important CE you will ever do
swhite53 : First of all, my sincere sympathy extented to both parents for the loss and I hope that the discussions of this tragedy results in measures being implimented to avoid repeat of such incidents.Although this occurred in hospital practice i hope this discourages the practice in retail pharmacy that seems to promote handling pharmacy dispensing like a fast food restaurant. Thank you Mr. Jerry for the support of theR.Ph.involved and for pharmacy.
plsummerfield : Thank you for your rational reaction to such an emotional event, Mr Jerry.
tamanhle : thankyou for the great lesson
kljansen : God is smiling down on you and your family.
espoba : Excellent program. My heart goes out to the Jerry family and I am glad to see Mr. Jerry turning this tragedy into something that will benefit many children, patients, and pharmacists.
figueredofamily : amazing man what a heart of forgivness
Moderator Holly : www.emilyjerryfoundation.org
kljansen : Thank you so much for tuning in Mr. Jerry. Best program I have participated in!
Moderator Holly : www.emiltjerryfoundation.org
copperfox04 : i agree, best program ever
jmathewrx : God Bless you and your family!
KierstenRxTN : Best program ever! Really made me think and will be sharing with my staff.
brandall : when the father found out this rph committed numerous other “documented” errors, didn’t he believe this rph was inexcusable?
RXGODESS : He’s right, dwelling on tragedy serves no purpuse.
[email protected] : I agree, Mr. Jerry is doing more for the betterment of medical safety than I would ever expect. He truly is a lightning rod for us
leighannwills : Mr Jerry has a wonderful heart! I say a prayer every time I go to work and would hope there are more people out there like him. My heart goes out to their family.
theninjacreeper : i wish hospital administrators had to go through these types of med error CEs
pharmergirl : Thanks for tuning in Mr. Jerry, our hearts go out to you and will affect our work ethic!
kitu_patel1 : thank you
pharmdman : doug105, employers take advantage of regulations that make it possible for state licensed employees (think doctors, lawyers) who don’t WANT to take a lunch to skip it. The employers twist that to say, “we’re not required to GIVE you one”
FRCCM : I think the pursuit of this RPh caused the subsequent mistakes.
hockeytonkman : I truly admire you for turning this tragedy into a positive issue in the name of your sweet daughter
docpharm : Mr Jerry- has your wife’s opinion of the pharmacist changed ?
Kent_Berry : Overly broad laws which allow lots of prosecutorial discretion are a huge problem. Don’t look for a DA to do the right thing anytime soon.
copperfox04 : @ ntran: so would i
kljansen : Thank you for your continuing efforts on such a huge problem
rosaki : I appreciate that Mr. Jerry is helping and advocating for the medical community.
sadie22 : What a great guy! He is making positive energy…
sadie22 : What a great guy! He is making positive energy…
dhshort : Wow
jimitajoh : More regulation will stop accident’s like this.
tljordan82 : @doug 105 i take a break every shift i work, its required by law therefore its my right unless i refuse to go
Eguadalupe67 : Was the hospital charged with anything?
bbruns1 : Mr Jerry – you are truly righteous
crackerfeet : there will be no regulations to make pharmacy safer because corporations control all of politics with their deep pockets and slick lobbyists
ntran : i’d feel hesitate to contact the family during their mourning time. i’d think they’d be angry to hear from me
jmathewrx : Does jerry think pharmacists should work 12 hours shifts without a break?
kljansen : Wow! Why can’t more people be like Mr. Jerry You are amazing
tljordan82 : maybe he should of reduced his hours becasue i know this caoused stress for his life in addtion to the job stress factors
doug105 : pharmacists dont even get lunch breaks!! really! in this day and age!
bhasegaw : Mr Chris J–doing more to prevent errors than anyone else in this whole thing.
[email protected] : Emily’s death was tragic, and my heart goes out to the family. I probably would have reacted in the same manner as the mother if I did not understand what pharmacists go through. Hold technicians just as accountable as pharmacists! I’ve heard a technician laughing when a pharmacist was reprimanded due to possible sabotage by this technician. This is ridiculous!
dorelsuboni : thank you Mr. Jerry
tljordan82 : he should of reported he other mistakes made after Emily’s death instead of leaving them undocumented. it looks as though he didnt learn from his mistake or care.
copperfox04 : i’ve worked at 4 different retail stores and they are all the same. they need regulations
jets1fan : FRCCM is right. Mr. Jerry is very dignified. I’m sure Emily is proud of him.
Ab124amb : It is a tragedy for all involved. We really have to put our foot down where our employer or work environment is concerned.

I received a very kind letter from Summa Healthcare’s Maria Giannakos regarding last week’s lecture. I wanted to share it with you all.

When I first contacted Christopher Jerry this past spring, my intent was a simple note of support and appreciation. Much time had passed since I had first wanted to contact him, but as both a new mom and a healthcare worker, I could not wait any longer.


When I first heard about Emily’s story years ago, I was a recent pharmacy school graduate and was finishing up my residency. From then on, I watched with sadness for the loss of a life, frustration with the focus on an individual rather than a process, and fear as the story of the tragedy unfolded and then landed in a courtroom. The fear I felt was shared by several colleagues, including pharmacists, physicians, and nurses, for we understood the precedent that was now set and the ramifications the verdict brought. The strides that had been made in error-reporting, open discussion of errors, and systemic analyses were left very vulnerable. There was hesitancy in the broader medical community to discuss errors, or even “near misses”, for fear of losing a job, license, or going to jail.


The compelling story of Mr. Jerry and Mr. Cropp joining together sends a powerful message against criminalization of medical errors and the negative impact on patient safety. The two courageous men share their individual perspectives about the same tragedy, and the effect all of us can have on patient safety. I wanted their message to reach as many people as it possibly could, which was my goal in asking Mr. Jerry and Mr. Cropp to speak at Summa Health System to an audience of healthcare workers, administrators, and patients. Listening to their story is an emotional and inspirational journey, one that provides hope and instills reflection. Based on audience feedback, Mr. Jerry and Mr. Cropp left our community with a deep respect, appreciation, and sense of empowerment.


Thank you for all of your efforts and contributions to improving patient safety.


Maria Giannakos, PharmD, BCPS, MBA
Clinical Lead, Internal Medicine | Pharmacy Services | Summa Health System
525 E. Market Street | Akron, OH 44309 | Phone 330-375-3164 | Fax 330-375-7622