An awesome blog post by Dr. Tim Vanderveen of CareFusion. I had the pleasure of meeting Tim after the ISMP speech and it was a great experience. We hope to team up early next year on an exciting webcast. As always, I’ll keep you updated via our website. Now without further ado, here is Tim’s blog posting…
Monday, December 12, 2011
A tipping point for preventing IV compounding errors
Dr. Tim Vanderveen – Vice President, Center for Safety and Clinical Excellence, CareFusion
Last week, I attended the American Society of Health-System Pharmacists (ASHP) Midyear Annual Meeting in New Orleans. While there, I attended the Institute for Safe Medication Practices (ISMP) CHEERS awards dinner – an annual event to honor individuals, hospitals and companies who have made a difference in patient safety. The dinner event included a speaker, Christopher Jerry, who came to tell the story of his daughter, Emily, a victim of a fatal IV chemotherapy compounding error. Emily was receiving her last round of chemo when the pharmacy technician used 24% saline to compound Emily’s chemo dose instead of the 0.9% saline that was ordered. In an earlier blog, I discussed the second victim of a medication error – the clinician. Eric Cropp, the pharmacist who checked Emily’s chemo dose faced criminal charges and served a six-month jail sentence followed by six-months of house arrest. Partnering with ISMP, the CareFusion Center for Safety and Clinical Excellence hosted a recent webcast that discussed the error and Eric’s experience during his jail sentence.
I am honored to have been asked by the President of ISMP, Michael Cohen, to be their keynote speaker at the 14th Annual ISMP Cheers Awards and Dinner at ASHP Midyear Clinical Meeting. The following is excerpted from a letter by Michael Cohen…
“We at the Institute for Safe Medication Practices (ISMP) are delighted that you have agreed to be the keynote
speaker at the 14th Annual ISMP Cheers Awards and Dinner on Tuesday, December 6, 2011. The event will be held at the New Orleans Board of Trade, 316 Board of Trade Place, New Orleans, Louisiana during the 2011 American Society of Health‐System Pharmacists Midyear Clinical Meeting”.
Below is a downloadable pdf flyer that details the ISMP event. Click on the image to download…
I gave a lecture last Monday, November 21st, at Ohio State’s College of Medicine in Columbus. Eric Cropp and I did this lecture together and everything went extremely well. We had over 130 students in attendance from OSU’s medical and pharmacy schools. I always look forward to these types of lectures and presentations to our future leaders in medicine. Read the amazing testimonial from Kenneth M. Hale the Assistant Dean for Professional and External Affairs, and Clinical Associate Professor of Pharmacy Practice and Administration. It is truly one of our most powerful recommendations to date!
Thanks to all who were in attendance.
Click the image below to download a pdf of the testimonial…
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.
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.”
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 AMI 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.
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?
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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!
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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..
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: December 16, 2011 by ejfadmin
2011 Recap
Below are a listing of all the speaking engagements and interviews I was a part of in 2011. I hope some of you were able to attend. Can’t wait to see what is in store for 2012. A sincere “Thank You” goes out to all those involved with making each and every one of these events a reality.
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Emily Jerry Foundation Completed Lectures and Presentations for 2011
Interview with Leon Bibb ABC WEWS “Kaleidoscope”- Cleveland, OH
Ohio Northern University School of Pharmacy – Ada, Ohio
Interview with Dr. Charles Denham of TMIT & Eric Cropp for Discovery Channel Segment “ Out of The Danger Zone”- Cleveland, OH
TMIT Webinar entitled “A Hospital Accident: Lessons Learned – A Death, A Conviction, and A Healing”
The Cleveland Clinic Foundation- Cleveland, OH
Sanford Brown College- Cleveland, OH
Pharmacy OneSource Webinar
Multiple Ongoing Webinars with Pharmcon entitled “Emily’s Act Revisited: The Pharmacist, The Family and the Medication Error that Changed Their Lives”
Summa Healthcare- Akron, OH
Catheter Connections- Salt Lake City, UT
Baxa Corporation- Englewood, CO
Union Hospital- Dover, OH
The Institute for Safe Medication Practices (ISMP) IV Patient Safety Summit- Philadelphia, PA
The Massachusetts Society of Health-System Pharmacists- Boston, MA
The Rhode Island Society of Health System Pharmacists- Providence, RI
Jewish Hospital- Louisville, KY
University Hospital’s Pediatric Pharmacy Team – Cleveland, OH
Ohio State University Medical Center- Columbus, OH