Emily Jerry was just two years old when she died from a medication error made by a hospital pharmacy technician in Cleveland. She had undergone surgeries and four rounds of chemotherapy to treat what doctors said was a highly curable malignant tumor at the base of her spine.
According to her parents, Emily’s previous treatments had been so successful that her last MRI showed that the tumor had miraculously disappeared. This last treatment on her second birthday was just to be sure that there were no traces of cancer left inside of her. Tragically, the technician mixed her final dose of chemotherapy improperly, in a saline solution that was 23 times more concentrated than it should have been.
Emily woke up after her treatment and asked her mom to hold her in her lap. She began to grab her head and moan that it hurt. Spotting her mom’s can of Coke she begged to have a sip. Then, in a matter of seconds, she drank the entire can. The massive amount of saline had already begun to cause her brain to dehydrate. She began crying again about her head hurting and then became limp. Within the hour she was on life support, and the following morning, doctors met with Emily’s parents to break the tragic news that Emily was brain dead. Instead of hosting a planned belated birthday and cancer-free party for Emily in the coming days, their little girl was delivered to the Cuyahoga County Morgue.
Because pharmacist Eric Cropp was the supervising pharmacist on the day this all happened, and was in a position to catch the error but did not, many family members as well as the media came down hard on him publicly. The Ohio Board of Pharmacy and, later, the county prosecutors, agreed that Mr. Cropp was responsible for the toddler’s death because he oversaw the preparation of her chemotherapy. Eric spent six months in the county jail.
As I wrote in a previous blog that touched on this case, I completely understand the angst and the call for retribution by families left behind in the wake of a fatal medical error. I also recognize they need someone to blame and to hold accountable for the pain of their horrific loss. But I truly admire one family member who took a different path, Chris Jerry, Emily’s dad. Almost from the start, he opposed Mr. Cropp’s jailing, and now he’s even forgiven him. In fact, Chris Jerry and Eric Cropp have been working together, traveling around the country to speak at pharmacy meetings to help create awareness of the vital importance of safety practices. I’ve received several emails from colleagues around the country who’ve attended these programs—enthralling is how they describe it.
Like me, Mr. Jerry believes in his heart that the greater good is served by focusing on hospital medication system failures that allow tragedies like this to happen. He argues that by focusing on those involved in the error, it’s too easy to avoid addressing the many systems issues or contributing factors, like those that literally set Mr. Cropp and the pharmacy technician up for failure. Our real power to protect patients lies in the systems we build around imperfect human beings. By “systems” I mean the clinical processes, technology, environment, educational programs, and the overall structure within organizations in which patient care is provided.
With this in mind, Mr. Jerry has also established the Emily Jerry Foundation in his daughter’s name. Among the foundation’s many objectives is to establish state and federal legislation that assures strict controls in professional training, education, and testing. At the time of the error, the Ohio Board did not even require the registration of pharmacy technicians. There were no standards for training and no licensing or certification requirements. That’s changed now in Ohio, thanks to Emily’s Law, which was passed in 2009. The law requires pharmacy technicians to be 18 years or older, possess a high-school diploma, pass a criminal background check, and pass a competency exam approved by the Ohio State Board of Pharmacy. The Foundation is working to assure that similar legislation exists in all states.
Mr. Jerry is also working with existing organizations that are dedicated to improving patient safety. Recently, I asked him to do the opening presentation at a 2-day national medication safety summit that my organization (ISMP) conducted here in Philadelphia with nearly 60 invited experts from around the US. The summit’s focus was on safe preparation of solutions that are given to patients intravenously. Attendees included experts from the US Food and Drug Administration; professional pharmacy, nursing, and physician organizations; representatives from companies that make the equipment used to prepare intravenous solutions; and practicing nurses and pharmacists. In planning the event, we knew that time would be tight for discussing all aspects of this important safety topic. Some members on the planning committee wanted to get right into the subject matter, without having an opening presentation. I’m glad I was successful in convincing other meeting planners to include this presentation because Mr. Jerry quite eloquently captured everyone’s attention immediately, reinforced the importance of the topic under review, and set the tone of the meeting with the mantra that we can do better.
While we are human and will make mistakes, we can build stronger healthcare systems that will prevent or capture human errors before they reach patients and cause tragic outcomes. The grave importance of safeguarding the preparation of intravenous solutions was repeatedly reinforced throughout the 2-day meeting when Mr. Jerry, along with the foundation’s executive director, Lisa Cappetta, added a “patient” and “family member” perspective to every discussion and challenged the group to address specific issues that otherwise might not have been addressed.
Chris Jerry worries, as we do, that regulatory and accreditation agencies have not learned enough from his family’s tragedy. He hopes, as we do, that all hospitals adjust their systems to prevent the same type of error. If not, the death of his little girl is a heartbreaking commentary on healthcare’s inability to truly learn from mistakes so they are not destined to be repeated.
To check out more Check Up items go to www.philly.com/checkup