
Emily Jerry was nearly ready to go home from a Cleveland hospital. The grapefruit-size tumor in her abdomen seemed gone, and the 2-year-old with blond ringlets and blue eyes was getting one last round of chemotherapy just to make sure.
Instead, the treatment killed her. A pharmacy technician at Rainbow Babies and Children’s Hospital mixed Emily’s chemotherapy drug with a saline solution 26 times above normal. The pharmacist on duty didn’t catch the error. Soon after getting the drug, Emily was on life support. She died three days later, on March 1, 2006.
On Tuesday, a House bill that would set mandatory education, training and regulatory standards for all pharmacy technicians, is scheduled to be introduced by Rep. Steven LaTourette, R-Ohio. He calls it Emily’s Act.
A similar proposal in Emily’s home state, Ohio, is expected to be considered this year by state lawmakers. And next month, the American Society of Health-System Pharmacists plans a drive for tougher standards for technicians, who in many states need prove only that they are high school graduates with no criminal record.
Emily’s parents, Kelly and Christopher Jerry, are at the forefront of the crusade for tougher standards for the workers typically responsible for entering prescriptions into computers, checking dosages and getting the correct drugs into medication containers. They say the circumstances of Emily’s death lend urgency to their cause.
“It would have been a whole other story if the cancer would have been responsible,” says Kelly Jerry, an activist and former school teacher in Concord Township, Ohio. “But to know that she died in this horrific way she did, we can’t live with ourselves until we help make changes so this doesn’t happen to another family.”
Emily’s parents say a USA TODAY series published earlier this month drew new attention to the cause by highlighting technician errors not caught by pharmacists.
Born in February 2004, Emily was diagnosed with a curable form of cancer when she was 18 months old. She underwent surgeries and four rounds of chemotherapy to eradicate the tumor growing from the base of her spine. The treatment worked, and Emily was expected to go home disease-free just after her second birthday.
Her parents planned a Disney World celebration trip with Emily and her older brother and sister.
Instead, Emily awoke crying on Feb. 28, grabbing her head in pain and vomiting. She died three days later.
An Ohio pharmacy board investigation showed that pharmacy technician Katherine Dudash had made a tragic error. According to a notarized statement Dudash wrote for the board, she prepared Emily’s chemotherapy bag with a 23.4% saline solution, 26 times the 0.9% normally used. Pharmacist Eric Cropp didn’t catch the mistake.
The board revoked his license last year over the incident and a string of later errors. In August, an Ohio grand jury indicted Cropp on charges of reckless homicide and involuntary manslaughter “in the death of Emily Jerry.”
Arguing that Cropp is innocent, defense attorney Richard Lillie has filed motions to dismiss the case, which is expected to go to trial later this year. Lillie says the charges raise “all sorts of land mines for health care professionals” who make unintentional errors.
Dudash, in her statement, wrote that she told Cropp, “This doesn’t seem right,” after preparing the intravenous solution for Emily’s chemotherapy. Cropp “shrugged it off,” she wrote. Joann Predina, a pharmacy board investigator, found Dudash had spent time on the Internet “planning her wedding” during a lull before the error.
Cropp, in his own notarized statement to the board, wrote that he had been rushed, “which caused me to miss any flags that Katie had done something wrong.”
Unlike Cropp, Dudash has not faced disciplinary action or prosecution. In part, that’s because Ohio is among at least 11 states that do not regulate pharmacy technicians. In Ohio, “The technician has no legal responsibility. It all falls back on the shoulders of the pharmacist,” says Tim Benedict, assistant director of the state’s pharmacy board.
After the fatality, Dudash returned to the CVS (CVS) drugstore chain, where she had worked and passed a technician training program before landing the hospital job. CVS spokesman Michael DeAngelis says she now holds a non-pharmacy job and would not grant interviews.
LaTourette, the congressman, says Americans “would be a little bit dismayed if they knew that they and their loved ones were having drugs mixed for them by people who don’t have any training requirements.”
His bill would make federal grants available to states that require all technicians — in hospitals, retail stores and other settings — to pass the national training exam administered by the Pharmacy Technician Certification Board. It would also require reporting of prescription errors to state pharmacy boards and limit the number of technicians supervised by a single pharmacist.
LaTourette says he will seek co-sponsorship from 20 members of Congress with constituents who were injured or died from errors by pharmacy technicians. He says the proposal has the backing of actor Dennis Quaid, whose newborn twins mistakenly were given 1,000 times the usual dosage of a blood thinner in November at Cedars-Sinai Medical Center in Los Angeles.
A hospital investigation showed technicians failed to follow hospital policies in checking the drug’s strength. The twins recovered. Quaid’s attorney, Susan Loggans, said the actor and his family “support the regulation of people in the health care field who are not certified.”
LaTourette is optimistic his bill will become law. But it likely faces an uncertain congressional reception in a presidential election year. Pharmacy operators are expected to oppose it as unnecessary and too costly.
Sen. Timothy Grendell, R-Ohio, who introduced the state legislation, said that measure has drawn “quiet resistance” from pharmacy lobbyists over the proposed pharmacist-to-technician ratios and the prospect of higher salaries for technicians who meet the tougher standards. Supporters say they hope the planned campaign by the 35,000-member pharmacist group will help overcome opponents’ arguments.
“I think they realize in light of what happened to Emily … that something is going to get done,” says Grendell.
“We want people like us to be able to protect themselves and be able to protect their families,” says Christopher Jerry. “The only way we can see to do this right now, immediately, is with the public outcry Kelly and I are trying to produce.”
Article written by Kevin McCoy and Erik Brady, USATODAY.com. It was originally posted on 2/24/2008.
Original article can be found here.
Last Updated: May 23, 2018 by ejfadmin
Emily Jerry Foundation endorses life-saving technology by CDEX
Non-profit supports the ValiMed™ Medication Validation System
by CDEX
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.