It’s been an extremely busy, but productive past few days, with respect to my advocacy efforts relating to the overall mission of the Emily Jerry Foundation.
Yesterday, I was so blessed to have the opportunity to present to such a wonderful and receptive audience at the Cleveland Clinic’s Medication Analytics, Safety & Technology Symposium. The presentation not only focused on improving medication safety and the prevention of medical errors, like the one that occurred with my daughter Emily in 2006, we also discussed, what is often referred to as the “2nd victim syndrome” and the overall impact that these tragic medication errors have on the health care providers, as well.
Then this morning, in Nashville, I had the distinct honor and privilege of being able to present to yet another amazing group of clinician caregivers & members of state boards of pharmacy at the 119th NABP Annual Meeting. During this presentation we described how “just culture” principles can be effectively used in evaluating and learning from medication errors. Our most important learning objective though, that I feel we truly accomplished today, was explaining how the use of tools such as continuous quality improvement can be utilized in the prevention of future tragic errors.
Yesterday evening, I had the opportunity to attend a wonderful dinner and opening reception for the Cleveland Clinic’s Medication Analytics, Safety & Technology Conference (MAST). This afternoon, I’m looking forward to participating in a CME titled “The Impact of Medication Errors on Healthcare Providers.” Afterwards, I’ll be heading to Nashville, where I feel very privileged to have another speaking engagement at the National Association of Boards of Pharmacy (NABP) 119th Annual Meeting. Tomorrow morning’s presentation is titled “Just Culture – Creating a New Regulatory Mindset.”
Last Sunday, I felt so blessed & privileged to have the opportunity to be able to meet and speak with Granger Smith and his wife, Amber, at Adventure Church in Delaware Ohio. He gave a wonderful sermon with a great message about navigating through the trials and adversity in our lives, by focusing on James 1:2-4.
The week before last I had heard about Granger, a musician from Texas, who was making his final music tour called “Like a River”. He had made the announcement & bold decision to leave a successful career in country music to focus on ministry at his local church outside of Austin. In addition, he also has an upcoming memoir that I’m looking forward to reading which is scheduled to be released on Aug. 1st. It’s called “Like a River: Finding the Faith and Strength to Move Forward After Loss and Heartache.”
On June 4th of 2019, he was planning to head to Nashville for the CMT Music Awards the next day and then go on tour. Naturally, he was enjoying that evening spending time with his kids before he left on his trip. While helping his daughter London with her gymnastics, his youngest son, River, fell into their pool. Granger did everything he could to get to him in time, but he was too late. His three-year-old son River had tragically drowned.
We have much in common, not just with the unimaginable loss of our children, but we seem to have similar sentiments and perspectives about how strongly the grace of God has truly worked in our lives ever since…That God uses ALL the trials we face in life, ultimately for our good and for His glory…that He never allows pain without a purpose (Romans 8:28) and ALWAYS has a plan for our lives, even when we don’t understand or can’t even begin to comprehend in the moment, what those plans could possibly be (Jer. 29:11).
“It’s very personal. But the overwhelming feeling was that if my story could help others, then it’s worth it, then it matters” ~G. Smith
Happy birthday my sweet baby girl in heaven! Even though you would be 19 years old today, you will always be my “baby girl” Emily! This time of year has always been so incredibly bittersweet for me. I love you and miss you so very much, but have such an inner peace and comfort, knowing that you are with the Good Lord now, and that I will see you again one day, where we will spend all of eternity together.
Ironically, in 2006, just like today, your birthday happened to be on a Friday. Despite the fact it was your birthday, after much conversation, your mother and I had made the tough decision to have you admitted to the hospital that morning, since this was to be your final three day round of chemotherapy. We were elated by the fact that only by God’s grace, a miracle had occurred, being given exactly the prognosis we had been hoping and praying for all along. We were told that the large tumor in your abdomen had completely disappeared and that this last treatment was supposed to make certain there were no residual cancer cells that might still be remaining that could possibly emerge later in life, causing you difficulty. Unfortunately, that Sunday, the day we were supposed to take you home and celebrate your recovery as a family, instead you went home to be with the Lord…a tragic preventable sterile IV medication compounding error occurred that horrible day, that ended up taking your life three days later, on March 1st.
Completely devastated, I remember thinking to myself, I don’t understand and can’t even begin to comprehend why this would even happen…You just cured her, now You’re taking her? Really? Now, I truly understand, what I didn’t back then. That God NEVER, allows pain without a purpose…“And we know that for those who love God all things work together for good for those who are called according to His purpose.” ~Romans 8:28
As a result, I am now convinced, beyond a shadow of a doubt, that your short life here on earth…coupled with your legacy, which I am so pleased to say, lives on in the hearts and minds of so many around the globe, was truly meant to save quite possibly thousands of lives going forward!! As your daddy, I am eternally grateful that God blessed and gave me two amazing years with you here on earth!!
Happy Birthday, I love you sweetheart!
Daddy
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Thank you for the kind comments I received from many caregivers, associates, and friends who have used Emily’s powerful story during the course of their careers in patient safety! We are truly making a difference.
Feeling extremely grateful and privileged to have been asked to give another CME accredited presentation at the Cleveland Clinic for their upcoming Medication Analytics, Safety, & Technology Conference in May. It brings back wonderful memories of one of my very first grand rounds lectures for the Emily Jerry Foundation at the Cleveland Clinic’s main campus over a decade ago…really looking forward to it!! 
Also, my sincere thanks for the kid words from both Sam Calabrese, Chief Pharmacy Officer at Cleveland Clinic, and Jeffrey Chalmers, Director of Pharmacy Informatics & Technology at Cleveland Clinic.
Today is “Giving Tuesday” and I’m really hoping that everyone will consider donating to the Emily Jerry Foundation, so we can continue providing vital programming & initiatives, like the Medication Safety Scholars Program, the Pediatric Safe Label Program, our National Pharmacy Technician Initiative & Interactive Scorecard, etc. We will never know exactly how many tragedies have been averted, or precisely how many lives have been saved…but isn’t just one life lost due to something that’s deemed “preventable,” way too many? Your generous contributions assist EJF in helping to stop tragedies before they happen by improving patient & medication safety overall, for everybody…ultimately, saving countless lives in the process!
Astoundingly, preventable medical error has been identified as the 3rd leading cause of death in the United States, claiming between 251,454, to over 440,000 lives annually. Unfortunately, tragic medication errors like the one that took my daughter Emily’s life in 2006, comprise the largest percentage of these deaths, nearly 50%.
I recognize, respect, and am extremely grateful for the simple fact that ALL healthcare providers, regardless of their modality, continually strive to ensure that every single patient receives care that safely delivers optimal outcomes.
Although, as the healthcare system’s medication experts, I have always viewed pharmacists as the providers best positioned to truly offer leadership and direction amongst their colleagues, with respect to the vital issues associated with overall medication safety within their facilities.
This is precisely why I am so pleased to announce that our first year for the Emily Jerry Foundation’s Medication Safety Scholars Program was such a huge success, awarding five student leaders their certificates of completion!!
Thank you in advance and God bless you all for your continued support of The Emily Jerry Foundation!
Make a charitable donation at: https://emilyjerryfoundation.org/donate/
As I’ve mentioned many times before, I consider my very unconventional career path, since my daughter Emily’s tragic passing in 2006, to be my true calling & my life’s work. Something I take very seriously every single day and always will. That said, naturally, sometimes I begin “hyper self-evaluating” and doubting the efficacy of my day-to-day efforts to help improve patient & medication safety overall…asking myself the same proverbial question, over and over again, “Am I really making a difference?” Every single time I have begun going down that path (more often than I would like to admit), I have been so incredibly blessed and encouraged over the years to receive such kind correspondence like this…a great reminder where I absolutely must keep my focus going forward…
“Chris, your courage to continue advocating for a system that failed your daughter years ago is admirable. I was not part of that particular system that failed Emily that day but I am part of the healthcare system and I have made mistakes and failed. I’ve heard your story many times and the main thing that stands out to me is your forgiveness. My heart sinks every time I hear what happened to Emily, my heart sinks every time I hear what happened to the pharmacist, but all I can think about when I hear about your forgiveness to the system and the pharmacist is Jesus. Only Jesus. You have taken a tragedy and saved many, many lives through your pain. You have been brave in your suffering. We need more people like you out there to help make us better. We could all live in the coulda, woulda, shoulda, but you are an example to so many to take what you have learned through a tragedy to ensure it never happens again. I know so many of us are thankful for your heart and your mission.
We can be better. We have to fight the fight and become safer for our patients. We have to be fully equipped to do our jobs to the best of our abilities each and every day.”
~Anonymous Healthcare Provider
Sixteen years after my daughter’s tragic death from a sterile IV compounding error, there’s a question that I always ask myself. I know this career path I’ve been on since Emily’s tragic passing is very unconventional, but it has not only become my full-time job, but it’s also become what I feel is my “life’s work.” I do it so passionately, on a day-to-day basis, for the Emily Jerry Foundation, because this is what I feel I’ve been truly called to do. With that in mind, I think everyone will understand, the question I continually ask myself is simple and straightforward…am I really making a difference?
After many lectures & presentations, admittedly, sometimes I naturally doubt myself and begin almost “hyper” self-evaluating in this way. Then it never seems to fail, I get blessed with feedback and much appreciated encouragement, like I just did with this very kind comment from Kenneth Komorny, the Chief Pharmacy Officer, at Moffitt Cancer Center, regarding my recent visit to their facility in Tampa, the week before last.
“Thank you, Christopher Jerry, for continuing to tell your story. It has motivated and continues to motivate me to continually assess for ways to make our hospital safer. Moffitt Cancer Center is committed to safety with the approving of an IV workflow that includes barcoding as well as gravimetrics for sterile IV compounds. It was such an honor and privilege to meet you. My hope is that you continue to run with endurance this race that is set before you. You are making a difference!!!”
This past Sunday morning, I flew from my previous speaking engagement in New Orleans, at the National Infusion Center Association (NICA)2022 Annual Conference, to Tampa for the two presentations I gave at Moffitt Cancer Center on Monday. Everything was all coordinated and hosted by the amazing Risk Management team at Moffitt. It was great to have the opportunity to be able to help them kick off Healthcare Risk Management Week at their world-renowned cancer treatment center!
As many of you are already aware, there are over 100 different types of cancer. Some of them are common, but many are rare and complex, requiring very advanced treatment methods, which unfortunately, provide an increased opportunity for “human error.” Obviously, Moffitt Cancer Center is ALL about saving lives by achieving exceptional outcomes from the treatment of many various types of cancer. This is precisely why I was absolutely elated to learn from their Chief Pharmacy Officer, Kenneth Komorny, that their facility is in the process of implementing a new sterile IV compounding workflow system that helps to eliminate “human error” from creeping into their pharmacy workflow, preventing compounding errors like the one which tragically occurred with my daughter Emily in 2006. For these reasons, I am totally convinced that Moffitt is making patient & medication safety, their #1 priority every single day, with every patient!!
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.
Last Updated: August 29, 2023 by Nick Pietravoia
Technology in IV Workflow Management Systems
Ever since establishing the Emily Jerry Foundation and beginning my journey down this unconventional career path, I have felt very strongly that it was imperative to help people understand and recognize the simple fact that “human error” is inevitable. No matter how well educated or intended a person may be, God made us ALL fallible. My primary objective over the years, has been to help prevent what happened to my beautiful baby girl, from happening to others. To accomplish this and save lives, I realized that this inherent “human error” component needs to be truly acknowledged, and subsequently, core systems, processes, and protocols, in healthcare designed around this fact.
This is why, I highly recommend reading this great article from Dr. Tyler Nichols, from ISMP, titled “IV Workflow Management Systems: A Century in the Making,” that was published in Pharmacy Practice News, last Friday.
Visit https://lnkd.in/g-64Eq_w, to learn more about this exciting technology.
As someone who has been a very outspoken proponent, over the years, for the smart adoption & implementation of technology, as the tools to help eradicate “human error” from the pharmacy workflow, I’m hoping and praying that you, the experts in the modality of pharmacy, will continue striving and “fighting the good fight” to make these lifesaving IV workflow management systems become a “standard of care” as soon as possible!
To all clinician caregivers, thank you for all of your ongoing efforts to improve medication safety and God bless you all for your continued support of The Emily Jerry Foundation!