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KETV Omaha: Heparin Overdose Kills Toddler At Hospital, Staff Investigated

Staff Overdosed Almariah Duque On Blood-Thinning Drug

OMAHA, Neb. — The Nebraska Medical Center is investigating its staff after the Wednesday death of a toddler from Texas who was given an overdose of Heparin, a blood-thinning drug.

 Hospital representative Andrea McMaster said NMC is paying the family’s expenses and will also pay for the funeral of Almariah Duque .

Duque was nearly 2 years old. She was recovering from multiple organ transplants, and gastroschisis, at the Nebraska Medical Center. She had been there since December.

She died Wednesday afternoon, after she was declared clinically dead Wednesday morning.

Read the rest here.

Hudson Hub Times: Family's efforts helped make trip to pharmacy safer

March 28, 2010
by Laura Freeman, reporter

Everyone makes mistakes. I routinely check my take-out orders before leaving a restaurant and check my receipt for the sale price before leaving a store, much to my husband’s embarrassment. Recently, two mistakes at a local pharmacy made me thankful there are people like the Jerrys who fight for all of us.

The Jerry family has championed Emily’s Law to help protect patients from pharmacy errors.

Christopher Jerry of Willoughby visited Council March 9 and shared the story of his daughter, Emily, who had been diagnosed with a treatable and curable cancer. By the time she was 2, the tumor was gone. It was February 2006 and she was undergoing her last treatment of chemotherapy when she received a fatal dose of saline solution — a sterile solution of sodium chloride, or salt in water, given intravenously.

“One error changed everything,” Jerry said. “I want to share my personal tragedy and how easily it could be avoided.”

Read the rest here.

RethinkingPatientSafety.com: Death Is Worse Than a Six Month Sentence

Legal proceedings about Emily Jerry triggered noise & public awareness

A February 26, 2006, Cleveland, Ohio, pharmacist’s error in mixing medication for two year old Emily Jerry took her life. Criminal prosecution of the pharmacist has generated detailed newspaper reports.

For too long, most errors have been ignored by the medical profession and the media. The deaths of children unrelated to celebrities are usually not considered “newsworthy.” I have not been able to find any news stories about Emily Jerry’s death published in 2006, the year she died. The earliest article I have found is a January 2007 article about “Emily’s Law” being enacted. The error was subsequently discussed in newspaper articles covering some aspect of the legal proceedings: the criminal charges against the pharmacist, the licensure hearings against the pharmacist, the pharmacist’s being released from jail, or the push for state regulation of pharmacy technicians. Without those events, I would never have been aware of this case. I fear that the public discussion of this case would not have occurred. Sadly, the only vehicle most families have to advance public discussion of medical mishaps are legal proceedings.

Read the in-depth report here.

US Pharmacist: Criminalization of Medication Errors

Jesse C. Vivian, BS Pharm, JD
Professor, Department of Pharmacy Practice
College of Pharmacy and Health Sciences
Wayne State University
Detroit, Michigan


US Pharm. 2009;34(11):66-68.

Here is a sobering thought. A pharmacist makes a mistake. The error results in the death of a patient, and the pharmacist is charged with negligent homicide. He is found guilty of involuntary manslaughter and faces up to 5 years in prison and a maximum fine of $10,000. Of course, his pharmacist license is revoked and chances are he will never work in the profession again. His crime? He did not check the accuracy of calculations used by a pharmacy technician under his charge to compound the concentration of sodium chloride in a prescription for a cancer chemotherapy solution.

Negligent? Yes. Accountability and responsibility? Yes and Yes. Malpractice? Yes. Loss of license? Yes. Guilty? Yes. But a crime? Prison term? For a mistake, albeit a mistake with a worst-case outcome? That is tough medicine to swallow. More important, how is justice served by putting this pharmacist in jail? The message to pharmacists and perhaps all other health care practitioners—watch out. There may be prosecutors out there just itching to put you away.

Read the rest here.

Our 501(c)(3) Tax Exempt Non-Profit Status is Official

The Emily Jerry Foundation has recently received the following letter of approval from the IRS notifying us our Non-Profit status has been approved! We are very excited and thankful. For all our generous donors out there, this should help you out come tax day. Thank you so much for your support.

View the IRS Determination Letter by clicking here

Cleveland: The News-Herald: Willoughby resident starts Emily Jerry Foundation


Friday, January 29, 2010

By John Arthur Hutchison
[email protected]

Willoughby resident Christopher Jerry has started a foundation aimed at increasing awareness and preventing medical errors like the one that killed Emily, his 2-year-old daughter.

Emily Jerry died in March 2006 when a pharmacy technician’s mistake led to the delivery of a fatal dose of saline solution.

Her death came three days after she received the lethal dose during what should have been her final chemotherapy treatment.

The grapefruit-sized tumor in her abdomen was gone and her parents were planning a trip to Disney World when the toxic mixture was administered.

The case was the basis for a state law called “Emily’s Law,” which Gov. Ted Strickland signed in January 2009. The legislation is intended to ensure pharmacy technicians have the training and experience to properly and safely dispense medications to Ohio patients.

Jerry formed the nonprofit group last year to push for similar federal legislation.

He said the foundation’s mission is to protect children from medical errors.

The foundation’s goal is to actively work to save lives as well as to make medical facilities safer by looking to partner with organizations and businesses to promote lifesaving technology.

The Emily Jerry Foundation recently announced the agency’s first partnership with Tucson, Ariz.-based CDEX Inc. The two organizations hope to build public awareness about the company’s chemical detection equipment aimed to ensure medical facilities deliver the right medications to patients.

“It’s a safety net that protects the patients and helps to guarantee the right drug and dose are delivered every time,” Jerry said.

The foundation aims to focus on areas where it can immediately and directly positively influence patient safety, he said.

The foundation is going through the filing process to become federally recognized as a charitable 501(c)(3) corporation, which would allow donations to be considered tax-deductible.

Jerry also is trying to move forward with his life after experiencing some legal problems that include a lawsuit he filed in September in U.S. District Court in Cleveland against the Lake County Sheriff’s Office, county commissioners, and the city of Painesville’s police, probation department and municipal court.

For more information about the organization, visit www.emilyjerryfoundation.org.

Emily Jerry Foundation endorses life-saving technology by CDEX

Non-profit supports the ValiMed™ Medication Validation System
Device is clinically proven to save lives

CLEVELAND, OHIO ─ Nearly four years after the loss of Christopher Jerry’s two-year-old daughter, Emily, the anguish over her accidental death lingers on. Now, as the head of a non-profit foundation working to prevent medical errors, Jerry is entering the new year with a renewed sense of purpose promoting an all-new life-saving technology in honor of Emily.

Today, the Emily Jerry Foundation announced a new partnership with CDEX, Inc. to build public awareness about its pioneering chemical detection equipment designed to ensure medical facilities are delivering the right medications to patients.

Jerry, who formed the non-profit group to push for federal legislation to avoid medical errors like the one that claimed his daughter’s life, is actively promoting the life-saving capability of the CDEX ValiMed™ Medication Validation System (MVS) as an imperative device in the prevention of human pharmaceutical errors. Jerry endorsed the product as life-saving equipment that could prevent the death of other toddlers.

ValiMed™ MVS is a technological safety net that provides protection from medication errors for patients, pharmacists and hospitals. The table-top device ─ engineered to eliminate mistakes made while mixing compounds at a hospital ─ uses a technique called enhanced photoemission spectroscopy to determine if the compounds are correct.

“I plan to do everything possible in my daughter’s memory to prevent these horrible tragedies from occurring over and over again,” said Jerry, president and chief executive officer of the Mentor, Ohio-based Emily Jerry Foundation. “Technology like the CDEX ValiMed™ MVS equipment is clinically proven to save lives and can prevent the death of other children.”

Emily Jerry died in March 2006 when a pharmacy technician’s mistake led to the delivery of a fatal dose of saline solution.  Her death came only three days after receiving the lethal dose during what should have been her final chemotherapy treatment.  The grapefruit-sized tumor in her abdomen was gone and her parents were planning a trip to Disney World when the toxic mixture was administered.

“ValiMed™ MVS is the only technology available today that prevents harm to patients from human errors in the compounding of high-risk medications,” said Jerry. “We can immediately begin saving lives with the ValiMed™ MVS system. Let’s act now to prevent any more senseless deaths from occurring by asking all medical facilities compounding intravenous medications to install and use the ValiMed™ MVS by CDEX in their pharmacies.”

CDEX is a Tucson, AZ-based company specializing in chemical detection technologies with a vision for saving lives and protecting assets. “We are proud to partner with and accept the endorsement of the Emily Jerry Foundation,” said CDEX Senior Vice President Gregory A. Firmbach. “The foundation’s mission of preventing adverse drug events from occurring aligns perfectly with the designed functionality of ValiMed™ MVS. Our system was designed as a final check to prevent medical errors in the compounding of high-risk drugs in the hospital pharmacy thereby saving lives, enhancing patient safety and eliminating that liability exposure for the hospital.”

Worldwide studies continue to show that human errors in the compounding of high-risk medications occur frequently, often result in death or serious injury and the diversion of medical narcotics is a continuing problem.

A University of Michigan study of the ValiMed™ MVS was published in the American Journal of Health System Pharmacists. During the study, five potentially serious medication errors were averted over an 18-month period at C.S. Mott Children’s Hospital in the University of Michigan Health System utilizing the technology. The research team received the 2009 American Society of Health-System Pharmacists Literature Award for Pharmacy Practice Research. For more information on the study, go to www.ns.umich.edu/htdocs/releases/story.php?id=6255.


About the Emily Jerry Foundation

The Emily Jerry Foundation was established in May 2009 on the premise that every child born into this world is truly a miracle. The non-profit organization was formed shortly after Ohio legislators passed Emily’s Law, which created licensing and minimum education requirements for pharmacy technicians. The foundation’s mission is to protect children from medical errors. The foundation is actively working to save lives as well as make medical facilities safer by partnering with key organizations and businesses to promote life-saving technology. Support for the Emily Jerry Foundation will ensure the organization can immediately begin saving lives. For more information or to make a donation, go to www.emilyjerryfoundation.org.

About CDEX
CDEX develops, manufactures and globally distributes products to the healthcare and security markets.  The ValiMed™ MVS product line provides life-saving validation of high-risk medications and returned narcotics.  The ID2™ product line detects trace amounts of illegal drugs, such as methamphetamine.  CDEX expects to advance its patented technologies to serve additional markets. To meet its plans, CDEX must strengthen its financial position as stated periodically in its SEC filings.  For more information, go to www.cdexinc.com.

Click here to download the official press release.

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Chris Jerry, whose daughter Emily died from a pharmacy technician’s mistake, starts foundation to push for national law

Chris Jerry still hears the screams of his 2-year-old daughter, Emily, after a medical mistake put her into agonizing pain and led to her death three years ago.

His grief was overwhelming, but it drove him to give meaning to Emily’s death, suffered at the hands of a pharmacy technician who mistakenly gave the toddler a fatal dose of saline solution.

To make sure no other child would suffer the same fate, he and others fought through the labyrinth of the Statehouse to gain passage of a law to govern pharmacy technicians. To hold the people who killed his daughter responsible, they fought for justice in both the criminal and civil courts.

Jerry won on all counts. The law was changed. The pharmacist who failed to supervise the technician was convicted. Jerry and his soon-to-be ex-wife, Kelly, won a $7 million settlement from Rainbow Babies & Children’s Hospital.

But the money did not take away his pain or make up for what he lost. Jerry’s life went into a downward spiral. His marriage fell apart, and he lost custody of his two children. He got into trouble with drugs and the law as he searched for a way to make something positive out of the tragedy.

Then it came to him — Emily’s Foundation.

Jerry, 41, of Willoughby Hills, decided to use a chunk of the settlement money to start a charity. He hopes the foundation will be active by the end of the summer to push for a national law to govern the work of pharmacy technicians and help prevent medical errors like the one that killed his daughter.

The foundation will also operate a Web site where grieving parents can come together to console one another and offer advice. A spokesman for T.S. Wrobel & Associates of San Francisco confirmed that Jerry hired the firm to form the foundation and to apply for nonprofit status.

If you would like to learn more about the application process involved in achieving nonprofit status, you can see this useful guide from the GoFundMe website that explains everything that you need to know.

Jerry will run the foundation and serve as an advocate for children’s health issues.

“I’ve learned from losing my daughter that there are large bureaucracies in the medical community,” he said. “Children are getting sick and dying because of mistakes and because drug companies are forcing hospitals to cut corners. We will present these kinds of issues and force change by bringing them to the forefront.”

On Feb. 26, 2006, the Jerrys went to Rainbow for what was to be Emily’s final round of chemotherapy to treat her cancer. A grapefruit-sized tumor had been found in her abdomen, but the regimen had been effective and the tumor was gone. Still, doctors were unsure if she needed one final treatment to eliminate any possibility that the tumor might return.

The Jerrys talked it over and decided to have the last treatment on their daughter’s second birthday. The following week they would all go to Disney World and celebrate her birthday and her victory over cancer.

But there would be no celebration.

Katie Dudash, a pharmacy technician, prepared the saline packet to be used in the chemo mixture. She made a new bag from saline concentrate. Dudash told investigators she didn’t know why she just didn’t grab a prepared bag of saline instead of mixing a new one. She said she was distracted because she was planning her wedding.

The saline solution she made was 23 percent salt. It should have been less than 1 percent salt. Emily screamed in pain when the solution was put into her body, then went into a coma.

Emily died March 1, 2006.

The supervising pharmacist, Eric Cropp, lost his license and pleaded no contest to involuntary manslaughter this May for improperly supervising Dudash. He is to be sentenced on July 17 and faces up to five years in prison. Dudash, who was not charged, agreed to testify if the case went to trial.

Kelly Jerry attended all of Cropp’s court proceedings in Cuyahoga County Common Pleas Court. Chris Jerry did not. He said he feels no anger toward Cropp.

“I feel very sorry for the pharmacist,” he said. “This guy is facing a prison sentence, and I know it was an accident.”

After Emily’s death, Chris and Kelly Jerry’s marriage crumbled. In early 2008, she filed for divorce. It is expected to become final this month.

Jerry admitted he had trouble coping with the loss of his daughter. Painesville police arrested him late last year for possession of marijuana and resisting arrest. His case was diverted to a mental health court for adjudication.

His wife took out a court protection order against him, which he violated once.

He sought psychological counseling as he searched for a way to work through his turmoil. But he never forgot his daughter’s screams and her pain. So he decided that to help himself he had to begin to help others.

Jerry began counseling families in local hospitals whose children were on life-support systems. He did not offer legal advice but simply was there as one who understands what they were going through.

“I can speak to these people because I have gone through something similar, I know what they need to hear,” he said. “I can relate to them in every way.”

And his work with Emily’s Foundation will give him a purpose.

“God gave me my big mouth and goofy personality for a reason,” he said. “I’m planning on running this full time. I feel like my daughter is watching over me, like my personal guardian angel, guiding me in my efforts.”

Christopher Jerry can be reached at [email protected]

Article written by Michael Sangiacomo, for cleveland.com. It was originally posted on 6/13/2009.

Original article can be found here.

Chris Jerry Interviewed on the Mike Trivisonno Show WTAM 1100

Triv was gracious enough to help promote The Emily Jerry Foundation and we can’t thank him enough for the support. Click play below to listen to the interview in mp3 format.