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!!
After the ASHP Meeting in Phoenix last week, I flew to New Orleans, where I was invited to speak at the Annual National Infusion Center Association (NICA) 2022 Conference. I spoke about the vital importance of accreditation & setting standards, as it relates to always putting medication & patient safety first, for EVERY patient, at infusion therapy centers across the nation.
These types of facilities offer a wonderful service. They provide convenient and comfortable care in a much smaller clinical setting, giving them the ability to really focus on each patient individually, ensuring patients never feel like just a number. In this way, these infusion therapy centers are providing extremely compassionate care, so their patients can receive their ongoing chemotherapy regimens and various other prescribed IV medications, from experienced nurse practitioners and a clinical team that they actually end up becoming well acquainted with during the course of their treatment, while at the same time, this takes the burden off the larger hospitals and healthcare facilities, as well…bottom line, the patients receive outstanding and, most of all, SAFE care at a much lower cost!!
Repost from Bichoy Gabra, RPh, CPh, PhD, Manager – Oncology Infusion Pharmacy Services at Moffitt Cancer Center
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Honored to hear and meet Christopher Jerry, President and CEO of the Emily Jerry Foundation for Patient Safety and Safe Medication Practices.
As we celebrate Healthcare Risk Management Week at Moffitt Cancer Center, Chris gave an amazing presentation to the Pharmacy Team today highlighting the mission of his foundation:
“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.”
Chris has been a relentless patient safety and clinician advocate who spreads a message of hope, FORGIVENESS, compassion, and collaboration, by turning an unimaginable tragedy, into inspiring positive change, globally in healthcare, in honor of his daughter Emily.
Chris lost his beautiful and beloved two-year-old daughter, Emily, after a fatal medication error in March of 2006.
Emily was scheduled to receive the last dose of etoposide to treat a yolk sac tumor over a weekend. The order was entered incorrectly as a stat order. The short-staffed Pharmacy team compounded it using sodium chloride 23.4% w/v solution instead of the desired sodium chloride 0.9% w/v solution while the Pharmacy computer system was down.
This error led to fatal consequences for Emily, forever changing the lives of her family and the healthcare community across the country.
The “Emily’s law” was signed in 2009 by Ohio legislatures: Pharmacy Technicians be at least 18 years of age, register with the State Board of Pharmacy and pass a Board-approved competency exam.
The legislation also includes specific provisions related to technician training/education and criminal records.
This past week, it was great to see so many friends & colleagues I’ve been blessed to work with in medication safety, over the past 13 years, at the ASHP Summer Meeting in Phoenix!
It was also such a pleasure to actually have the opportunity to meet three of the five Medication Safety Scholars, in person, and also have the privilege of co-presenting with the faculty from this past inaugural year of the program. The title of our session was, “Learning from Our Mistakes: Engaging the Next Generation of Medication Safety Leaders.” I’m elated to be able to say that our very first year for the Medication Safety Scholars Program, far exceeded all my expectations and was a huge success!
Now it’s off to the next one…this morning, I’m heading to New Orleans, where I’m looking forward to speaking at the NICA 2022 Annual Conference tomorrow!!
Due to the pandemic, for the past few years, I’ve had to give all my patient & medication safety presentations for the Emily Jerry Foundation virtually. As a result, I have been hoping and praying that I would be able to get back to doing the live speaking engagements again, as soon as possible. After being submersed working with the clinician caregivers in the various modalities in healthcare, for well over a decade now, I was really starting to miss the direct interaction. Well, I’m pleased to say that my prayers were answered, and much more abundantly than I ever anticipated!
Along those lines, this month began on such a great note. Last Friday, June 3rd, I felt blessed to be able give a keynote at the first inaugural Pacific Coast Patient Safety Conference, in Long Beach, California. It’s always wonderful to have the opportunity to meet and attend the educational sessions of other likeminded people, who are just as passionate about patient & medication safety as I am. In addition, it was also great catching up with all those that I truly respect and have had the privilege of working with over the years that I haven’t seen in person in quite a while.
For these reasons, even though next week is going to be extremely busy and my travel schedule a bit hectic, I’m truly looking forward to ALL of it! The following are my next three upcoming events. If you’re planning on attending, I really look forward to connecting with you!
-Monday, June 13th, ASHP Summer Meeting, Phoenix, AZ
-Friday, June 17th, NICA 2022 Annual Conference, New Orleans, LA
-Monday, June 20th, Moffit Cancer Center, Tampa, FL
I’m really looking forward to heading to California next month, feeling extremely blessed & privileged to have been asked to give a keynote at the upcoming inaugural Pacific Coast Patient Safety Conference!
To learn more about this wonderful event being hosted for all modalities, including front line nursing, pharmacy, medical professionals & leaders, etc., by the California Society of Health – System Pharmacists (CSHP) and the Chapman University School of Pharmacy (CUSP), just click on the following link: https://www.cshp.org/page/pcpsc_2022
Really looking forward to speaking at the National Infusion Center Association (NICA)’s upcoming annual conference in New Orleans June 17th and 18th. If you’re attending, I look forward to connecting with you! #NICA2022
Just got home last night from the BD GCS Leadership Summit that was held this past week in Las Vegas, it was a great event. I feel so blessed to have been given the opportunity to share Emily’s story and all the important lessons that have been learned since her tragic death in 2006 from a sterile IV compounding error. After my presentation, which was very well received, I was extremely grateful for the individual conversations that I was able to have throughout the day with all the wonderful people from BD that were in attendance from around globe. Everyone I spoke with was eager to talk about the Emily Jerry Foundation and our programming, however I was pleased to see that they seemed especially interested in our National Pharmacy Technician Initiative & Interactive Scorecard. They were very enthusiastic, about finding ways in which we will work together going forward to improve the grades in the different states in their regions. I truly felt like we were all on the same page, all of us, understanding and agreeing, that this is an enormous public safety issue, and by improving individual state scores, we can immediately make the residents of those states safer together, ultimately saving countless lives!
I’ve always said, had the facility where Emily died, had simple barcode verification technology implemented in their workflow, that horrible day the pharmacy technician made the compounding error, my little girl would still be with us today. As I recently mentioned, in an editorial I co-authored in the American Journal of Health-System Pharmacists, the use of barcode technology is widespread at retail checkout counters, yet sadly, the technology is only being used in one-third of healthcare facilities preparing medications going directly into a patient’s circulatory system. This is exactly why I feel so strongly that IV workflow systems save lives and that systems like BD’s Pyxis IV Prep, absolutely MUST become a standard of care, as soon as possible. This is a vital issue that affects each and every one of us, and more importantly, all of our loved ones, due to the simple fact that we ALL receive healthcare during the course of our lifetime!
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: November 28, 2022 by Nick Pietravoia
Kind Words on Our Work from Anonymous Healthcare Provider
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