After Loss of Daughter, Father Stresses Education
To Prevent Medication Errors
On the final day of the AAMI 2013 Conference & Expo, attendees sat captivated as they listened to the powerful story of Christopher Jerry, whose 2-year-old daughter died as a result of a medication error.
“She was a tough little girl, who didn’t complain,” Jerry said of his Emily, who he called his guardian angel. In the wake of his loss, he has served as a champion of medication safety and eliminating hospital errors.
“I want to impress upon all of you that we all join together and truly focus on the human error component,” he said. It’s not a culture of blame that we should have, but one of forgiveness and finding ways to prevent future deaths, he added.
Jerry’s journey to this point began in late 2005. Emily had been undergoing chemotherapy to treat a yolk sac tumor and had been doing very well. She actually gained weight—something not seen typically in cancer patients. Miraculously, the cancer seemed to disappear, and she was about to be sent home in February 2006. However, the physicians in charge of her care decided to give her one more round of chemotherapy to eliminate any residual cancer cells.
However, just a couple of days after her second birthday, a medication error led to Emily ending up on life support. As part of the chemotherapy regimen, a pharmacy technician had compounded a bag of concentrated sodium chloride solution of 23.4% instead of using the standard bag with less than 1%. An overdose of sodium chloride can lead to death, especially with a young child. Eric Cropp, the pharmacist in charge, did not catch the error, and Emily received the dose. She experienced massive brain damage, and her parents eventually made the agonizing decision to remove her from life support. Cropp was held responsible for the child’s death, and was sentenced to jail and probation.
Despite his tragedy, Jerry said he didn’t experience the same anger others did in this situation—just a profound sense of loss. As he brought his daughter’s belongings back to his vehicle, he momentarily considered taking his own life. But then he felt as if his daughter was near him, telling him to stop—that he must be the one to work toward preventing medical errors so other families don’t go through the same tragedy. That was the genesis of his organization The Emily Jerry Foundation, whose mission is to make the nation’s medical facilities safer for everyone.
Currently, Jerry speaks to audiences throughout the country about his daughter’s tragedy, focusing on the themes of forgiveness and education. He also is pushing for better training for pharmacy technicians so they can prevent medication errors from happening.
Humans will make mistakes, but there are ways to reduce the number of errors and save lives. And it’s about working together, not pointing the finger of blame and punishing people—that will only lead to more mistakes, he said. By establishing a just culture and a nonpunitive type of environment, he said that healthcare professionals would not become secondary victims of tragedies, instilling fear and hindering error reporting.
Jerry even made it a point to meet with Cropp, and the two have worked together to bring attention to this cause. During his speech, Jerry showed a video that captured an emotional meeting between himself and Cropp, after the latter’s release from jail. “We all need to work together to change underlying opinions and attitudes,” Jerry said, adding that he is starting to see a culture shift in healthcare. Among the potential solutions mentioned by attendees were establishing credentials, certification, and further education.
In a question-and-answer session that followed Jerry’s speech, several audience members thanked him for sharing his story, saying he had helped to underscore the human side of medical technology. And they delivered a standing ovation once the presentation was over.
The Emily Jerry Foundation website includes a scorecard rating states’ pharmacy technician regulations to show proof of competence. There are several states with B scores, and five with A ratings: Louisiana, North Dakota, Texas, West Virginia, and Wyoming.
On the flip side, 23 states have a D rating or lower, while six have no regulations whatsoever.
To find out more about the foundation, please click here.
Posted: 06.05.13