Christopher Jerry of the Emily Jerry Foundation shares the tragic story of an accidental medication error that took his daughter’s life. Then, he takes us on a journey of working passionately through advocacy to be part of the solution to preventable medical errors through modification of internal systems, processes, and protocols in medicine. Learn more about the Emily Jerry Foundation at https://EmilyJerryFoundation.org/.
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Transcript: How to Prevent Medication Errors
Amanda Brummitt: We Infuse podcast, episode number 48. Welcome to the We Infuse podcast. My name is Amanda Brummett. In every episode, we give you a seat at the table as we talk to infusion center owners, operators, and experts, so you can get the insight you need to run a thriving practice. In this episode, we talk with Christopher Jerry, president and CEO of the Emily Jerry Foundation. Chris shares the tragic story of an accidental medication error that took his daughter’s life. Then, a journey of working passionately through advocacy to be part of the solution to preventable medical errors through modification of internal systems, processes, and protocols in medicine. Hi, so as I said, we are here today with Chris Jerry from the Emily Jerry Foundation. Chris, thank you so much for being here with us today.
Chris Jerry: Oh, thank you for having me, Amanda. It really is, Great to, be here, today.
Amanda Brummitt: Yeah. Well, I know a lot of our listeners as Infusion Center owners and operators are possibly familiar with the Emily Jerry Foundation and the story, of what happened to your daughter, but can you share us in your words, both the miracle and then the tragedy of what ultimately created the Emily Jerry Foundation?
Chris Jerry: Definitely. And I’m glad that you, started off with, asking me about the miracle that occurred, Amanda, because that’s very important and that often, gets lost, in, the story. In, the summer, or actually late summer, early, fall of, 2005. Emily was, diagnosed with a, large tumor in her abdomen. And, and it was very shocking to Emily’s mother and I, because Emily appeared to be, and, I thought, just seeing her visually, the only indication she had was every once in a while grabbing her side, wincing in pain for like just a brief moment and then she’d be right back to doing what she was doing. And, after I noticed it a couple of times and then her mother. noticed it a couple of times we decided to take her in and have her looked at we didn’t think it was anything serious and they ran her through, the MRI scanner and lo and behold, she’s got a large tumor in her abdomen and, the oncology team reassured us and, explain to Emily’s, mother and I that, the course of treatment that they were recommending, was chemotherapy where we bring Emily in, three days every month. And, they were treating her going to treat her with a topazide, was, the actual chemo drug that they were using. And they told us to expect the fact that Especially right after, each three day period, Emily would be exhibiting flu like symptoms. Most likely she’d be vomiting quite a bit, fever, she’d start to lose a lot of weight, and certainly lose her hair. And Amanda, we took her in for her first three day round of chemotherapy and brought her home. And I took Emily out of her car seat in the SUV. And what is Emily immediately doing? It’s she wasn’t vomiting or getting sick. She was wanting to run over to the play area, the swing set and go and play. And my point is, throughout Emily’s five months of chemotherapy, Emily didn’t really exhibit any of those flu like symptoms, really. I don’t remember her really vomiting at all. And we only really had to treat a low grade fever. She didn’t start to lose her hair until the end. And she was their first pediatric oncology patient to not lose any weight, but actually gain a pound, I was told. And so naturally, come January of 2006, towards the end of January, we as her parents along with the oncology team were starting to think that maybe this chemotherapy isn’t working and we need to get her onto something else. And they run her through the MRI scanner again, and lo and behold, the miracle that they discovered, and the word miracle, was not just used by us, it was used by Emily’s oncology team. Because they’ve never seen anything like it. When they ran her through the MRI scanner, lo and behold, the tumor had disappeared from Emily’s abdomen. Not only did it disappear, there wasn’t even any residual scar tissue remaining from that large mass. that they thought, that we all thought, was going to have to be surgically removed. And so we were all naturally, really excited about that prognosis. the treatment team, then explained to us, though, that they were recommending one final three day round of chemotherapy. Just to make absolutely certain that there wasn’t any residual cancer cells hanging out in Emily’s body that could pop up later in life, metastasize and, cause her difficulty. And that course of treatment made sense to me then, and even despite what happened, it still makes sense to me today. We brought Emily in, we thought we’re getting ready to cross the finish line here. My wife and I actually decided should we bring Emily in for her last three day round on Friday, February 24th, which was her birthday and actually begin her first day of the three day round of chemo on her birthday, celebrate her birthday at the hospital, her second birthday at the hospital and, with the hopes of bringing her home on Sunday. And so we did that. And when we brought her in on Friday, it was amazing because by then, word had traveled throughout the facility about Emily’s story, about the tumor disappearing. And I’ll tell you Amanda, there were so many wonderful clinicians just amazing. Spoiling my little girl, bringing her cookies and cupcakes and cards and all kinds of stuff. And it was very, Emily’s chemotherapy went well. They administered that, but, they just spoiled and loved her up. And, on Friday, everything went well on Saturday. And on Sunday is when, a pharmacy technician, who didn’t know any better. Instead of using a standard off the shelf bag of saline with 0.9 percent sodium chloride, she saw three vials of what’s called hypertonic 4 percent sodium chloride. She, took that, the hypertonic saline and manually withdrew that, filled an empty compounding bag with that. used that as the base solution for, Emily’s, chemo and did not add any diluent to that. And, the pharmacist signed off on it and it was sent up to Emily’s floor. And unfortunately, when somebody is overdosed on, of all things, salt, that causes immediate cerebral edema or brain swelling. And unfortunately, they had to induce Emily into a coma. And, three days later. My wife and I had to make, after multiple EEGs showed little to no brain activity, my wife and I had to make the worst decision of our lives. When I would hope, no parent ever has to make for their child. Although I know that they do unfortunately sometimes, which was to take Emily off of life support. That’s where the foundation, got its start after, hearing Emily’s story. Many people. Will ask me. Most people will ask me two very pointed questions. The first one is Chris, weren’t you? You know that horrible day you just described, weren’t you mad as hell at the facility where it happened? And then the second question is, weren’t you mad as hell at the clinicians that were involved? And I know it sounds odd, but I’ll explain the honest answer to that is no. I skipped over the natural second stage of grieving that virtually everyone goes through, which is anger and rage. Everybody tells me, Chris, I don’t know how you did that. Because if that was my baby girl, I, how did that happen? How can you stand, how can you sit there and say, no, I believe it’s for two profound reasons. first of all, let me explain. I was emotionally traumatized. Yes, without a shadow of a doubt. And I was definitely looking up saying, really? You just cured her? Now you’re taking her? I didn’t understand. But the reason I say I skipped over the natural second stage of grieving, first and foremost, I believe was due to the grace of God, because I’m just a regular guy. But a very close second to that was during that very scary time when Emily was first diagnosed with having a large tumor in her abdomen that We didn’t expect my wife and I did not expect that initial diagnosis during that very scary time. Like any parents would, when we first started the Emily’s chemotherapy regimen and all throughout her treatment, we were watching every clinician caregiver that came in contact with Emily, like a hawk so closely, every medication that was administered, everybody that came in contact with her, the nurses, the oncology team, everybody, but especially the nurses. And what we witnessed, what I witnessed was what I believe healthcare should be. And that was, these nurses loved my little girl up and took care of her like she was their own. And not just because we were watching them so closely either. this is how they took care of all of those, little ones on that pediatric oncology floor. And so I really believe that I skipped over that. natural second stage of grieving, anger and rage, because also because of the fact that I witnessed healthcare, how it should be in these wonderful clinicians. I knew in the back of my mind that none of these clinician caregivers meant for this horrible error to happen. That’s, the worst possible scenario. They were all grieving just as much as, my wife and I were over the loss of Emily. And, That came through crystal clear. After all of that, I knew Emily was with the Lord. I knew that I’m going to see her again one day. But shortly thereafter, I became obsessed with, I didn’t know quite, immediately how I was going to do this, but I wanted to make certain that I was doing everything to uncover where did, the systems, processes, and protocols break down that horrible day. to set these amazing clinician caregivers up to fail. I wanted to find out how, exactly how the error occurred. And then, this time was a blur in my mind. I believe it was a few weeks thereafter, my wife and I learned about the, root cause analyses that was done at the facility. After learning the details of it, initially right after Emily died, I thought that this was just a freak accident and the probability of it happening to others was probably pretty low. But then we learned the root cause analyses and I started doing some more research on the internet and I came across, the IOM’s, report that came out in, 1999, I believe. called to air as human and they were trying to, they were trying to, the IOM was trying to estimate how many people in the United States die every year from preventable medical air. And I about fell out of my chair, Amanda, because they, said they put the, their estimate and it was a conservative estimate at a hundred thousand lives lost every year to COVID. preventable medical error. And then naturally, my next question was, what percentage of those are due to preventable medication errors in particular? And I, I was told by the experts then that medication errors comprise the largest percentage of deaths from preventable medical error every year. And I actually talked to some of those people that were on the IOM that came up with. That report to air is human. And they told me the same thing and that preventable medication errors comprise nearly half of all of those deaths from preventable medical errors, which is an astounding number. And that’s when I discovered that, this is not what happened to my daughter was not a freak accident with a remote possibility of happening to others, that this was something that, affects each and every one of us and all of our loved ones. Why? Because we all receive health care during the course of our lifetime. Now, that’s the bad news. That’s the shocking news. I think the good news is, I believe that, we can fix this. If we focus on fixing the systems, processes, and, protocols in healthcare and, taking that systems approach to, to really focus on ways that we can eradicate human error from creeping into both the pharmacy workflow in healthcare and the clinical workflow. Not only during the, like in my daughter’s case, in the sterile IV compounding processes, but then also in the clinical workflow in the medication administration phase of things. And I think that’s how we can, fix things because these errors, I always go back to the simplest point and that is that the mere fact that they’re called preventable means they don’t have to happen. Right? And, because they don’t have to happen, and because I have such respect for clinician caregiver experts in their different modalities, I really believe that, we can, fix these broken systems, processes, and protocols, and prevent the types of tragedies that happened to my daughter. before they happen and ultimately just save countless lives together.
Amanda Brummitt: Wow. I love the concept of working together with the caregivers to save lives. Makes a lot of sense and is actually one of the things that I thought was really remarkable about your story. Those caregivers that you were speaking of that cared for your daughter, including Eric Kropp, the pharmacist, how you’ve actually come together. made them part of the solution going forward and collaborated with them. can you share with us about that?
Chris Jerry: Definitely. These clinician caregivers, what everybody needs to remember is that, well, I explained the way that, I grieved and responded immediately to what happened. The only thing I could focus on during this difficult time, and I still remember vividly working out of my small apartment. This was a horrible time for me, but I tried to focus all of my energy on how was I going to establish the Emily Jerry Foundation? And what was I, what types of activities or programming would the Emily Jerry Foundation be involved in? And I didn’t know quite how I wanted to do it, but I knew that I didn’t want to just be the person that calls themselves a patient and medication safety advocate with an emotionally traumatizing story to share with everybody. And then I leave or, just stop with that. I wanted to be a part, active part of the solution. And so I just began, working day in and day out, not only to establish the Emily Jerry Foundation, it’s a registered 501c3 charitable organization, which I’m pleased to say has been now, in established 501c3 since 2009. So 13 years, but I was also picking up the phone and just calling every expert like from the IOM and anybody who would answer the phone and talk to me. And there were quite a few people that did. The one day I’m working and making all these calls, my phone started ringing off the hook. And it was the news media. And the first person to, call me from the news media was a reporter from CNN named Tristan, who was asking for an on camera interview. And I said to him, Tristan, what’s this all about? He said, it’s about your daughter, Emily. I said, that news broke, two years ago, almost three at that point, I think.
Amanda Brummitt: Wow, Chris, that must have been such a shock. Now, this is the point at which you learned about the criminal charges against Eric Kropp. How did you respond to the reporter?
Chris Jerry: I said, I wasn’t aware of that. And I said, furthermore, there were two root cause analyses that showed that no one person responsible for my daughter’s death, that there were multiple systems failures that led up to my daughter’s death. And so at that time, at that point in my life, which was a very difficult time, I just decided to decline all the on camera interviews and bow out of the media spotlight. And Amanda, I was horrified at what I saw. They were charging, this man with, things like reckless homicide, involuntary, manslaughter, which is what he was ultimately charged with, so on and so forth. Very similar to what’s going on right now with, this, I believe her name is, Redonda Vaught. in Tennessee with a nurse and I was horrified to see what happened. He was actually sent to jail and when he was sent to jail, then I started to actually feel, I kept thinking in my mind, if this is how we respond as a society, when these types of errors occur, then the emphasis is going to be taken off of fixing broken systems, processes, and protocols because people are going to think naturally. We’ve got the person that’s responsible. They’re rotting in jail where they belong, right? We don’t need to, address the issue anymore. And I actually started to feel a sense of guilt. And this is something that I apologized. Well, first, let me explain. this is something that I apologized to the man for his name’s Eric, crop afterwards. I started to feel a sense of guilt for not, it was one of those things that if I had to do over again, I would have, stood up publicly and maybe called Eric’s, legal counsel and helped with his defense. That’s how wrong it was in my mind. And I felt guilty for not doing that afterwards. And this guy went to jail for what happened. And, I was watching a, patient safety documentary called Chasing Zero on Discovery Channel the one day that was, produced by a gentleman by the name of Dr. Charles Dunham. And in that documentary, they had done, they had talked about, and, actually had Dennis Quaid in it. In that, documentary talking about, the heparin overdose with his, twin, I believe daughters, fortunately, praise God that, his daughter survived and there’s no, there don’t appear to be any long lasting problems as a result. but in that, documentary, they also had a, they had interviewed Eric Kropp while he was in jail. And so naturally, immediately after watching that documentary, I wrote down, Dr. Denham’s, name and I immediately found a way to contact him and I reached out to him and he and I became acquainted and, started talking and became friends, started talking on the phone and, I told him about how I felt about Eric being incarcerated for what happened to my daughter’s death. And he called me up the one night, I’ll never forget it, and we had a conversation. I had told him earlier that, Chuck, at some point, I would love to have the opportunity now, going forward, to publicly forgive. Eric for what happened in my daughter’s death to put the focus back on fixing the broken systems processes and protocols. Because it, it broke my heart, Amanda, when I saw this man in jail saying, this is Jerry, I hope one day you can forgive me, And I told Chuck that and Chuck called me. It was a few months later after I heard that conversation, he said, Chris, he said, I’ve got an idea. He said, I’ve stayed in contact with Eric since we did that. interview when he was in jail. He’s been released. I’m going to be producing a second follow up patient safety documentary. for the Discovery Channel. What if I gave, you that opportunity, to publicly forgive Eric, surfing the healthcare tsunami? and, I said, Chuck, that would be such a, blessing. So he made the arrangements and Eric and I were actually brought together on camera in May of 2011. And I was given that opportunity to publicly forgive Eric and set the record straight. And then shortly thereafter, Eric and I, again, it may sound odd, but I don’t care. Eric and I actually became friends and, we made a promise to one another to try and make some good come from all of this. And, he and I did probably about a dozen or so. lectures and presentations, all over the United States that following year or two. And we still continue every once in a while. We just did, a really nice CE, last week. it was an hour and a half, webcast. And, we had approximately 800, pharmacists and nurses from all over the United States.
Amanda Brummitt: That is really incredible that you and Eric now actually teach other healthcare professionals together. I really like that. And what a beautiful example of humanity and how you two came together and are doing good things. to help health care.
Chris Jerry: Yes. Thank you, Amanda. Thank you.
Amanda Brummitt: As I understand, through that relationship, that is also how you came to meet who our listeners met a few weeks ago, Chuck DiTropano with RxToolkit, and you two have collaborated as well.
Chris Jerry: Yes, we have. Chuck is, not only have we collaborated, Chuck has, become not only a good friend, but, very much a mentor, for me. And, I’m very pleased to say, he’s been a longstanding, board member. of the Emily Jerry Foundation and, has provided a lot of, guidance, for the foundation in terms of our programming and, what have you. And, Chuck, was a, a, pharmacy, director, if you will. I don’t know exactly what his title was, but he was in a supervisory role at Reading Hospital in Pennsylvania. And, he and I, he reached out to me, I think around 2013, and, he, had initially reached out to, to Eric, again, right after Eric was released from jail and had Eric come and speak at Reading Hospital to, the clinician caregivers there about, the second victim. and how, which is second victim is a term coined by my friend, Albert Wu from Johns Hopkins. The second victim refers to all of those wonderful clinician caregivers that I had mentioned, like in Emily’s case. And people like Eric that, this is their worst possible nightmare. They went to, we have to remind ourselves, they went to nursing school, pharmacy school, medical school, not with the intentions of harming anyone. Certainly that’s horrible. They went to school and they do their jobs day in and day out to help people, to help improve their, their quality of life. These are the most empathetic, compassionate people I know. And when something bad like this happens that’s totally unintended and a result of the systems, the flawed systems that they work in, then imagine how devastated they are. And, they’re, in the business of saving lives. And so, Eric came to the, Redding facility, after Chuck invited him and, gave these presentations. And then, shortly thereafter, Chuck invited me to come and, speak. And, not only did he invite me to speak, he, had me, come in and he, gave me just a wonderful tour. of their very large facility there. And, it’s a wonderful system that he had developed and actually implemented there at Reading, called RX Toolkit, which I’ve been a very outspoken proponent since day one for the smart adoption and implementation of technology as the tools. To help eradicate human error. And, Chuck showed me, exactly how RxToolkit helped to, minimize the probability of human error from creeping in and actually showed me the implementation there at Reading. And, I was so impressed and he and I became, good friends and, the rest is history.
Amanda Brummitt: I especially appreciate Chuck’s approach about making infusion safer for both the patient and the caregiver. he really opened my eyes to that whole second victim side, which you’re right. we all forget about how traumatizing it is for that person as well.
Chris Jerry: And then it just, and I’m glad you’re really emphasizing the second victim, Amanda, because again, going back to. Like, not only Eric Kropp, but now immediately, I keep thinking about, Redonda Fahd. As I understand it, at her sentencing hearing coming up here in, in May, this woman is facing, like, I, I believe, four to eight years. in prison. Now, how is that going to make anyone safer that’s receiving care? She did not intend for that horrible error to happen. Bottom line, that’s going to negatively impact a very important aspect of patient medication safety. And that very important aspect is people like Chuck and myself and everyone else involved in patient medication safety has been advocating for ways to improve error reporting.
Amanda Brummitt: Absolutely. In a culture where it’s safe to report.
Chris Jerry: Exactly. And now with these types of punitive measures, Being shown and displayed, if a another nurse has a good catch, let’s say, or a near a medication error that doesn’t really reach the patient that they catch at the last minute.
Amanda Brummitt: Right./p>
Chris Jerry: Are they going to tell their supervisors or share it with their peers?
Amanda Brummitt: No, they’re going to hide all the near misses.
Chris Jerry: They’re going to hide all the near misses and nobody’s going to learn because if, that nurse had a near miss, then another nurse can have the exact same type of near miss. And we don’t learn. So this has all kinds of, ripple effects. It’s throwing a rock in the pond and, seeing the ripples, go out in the water.
Amanda Brummitt: Absolutely. Well, Chris, I could talk to you about this all day because it’s something I know you’re passionate about. I am too. And I know all of our listeners care about, and that’s why they went into this. But if you had to boil it down to just one piece of advice that you would give to infusion center owners and operators. to positively impact patient care and their caregivers? What would that one thing be?
Chris Jerry: The one thing would be to always stay vigilant and proactive about where human error could creep into your Pharmacy and clinical workflow. And once you determine where human error can creep in, be proactive and implement measures that, that will hopefully, help minimize that human error from actually causing an error. And, to always, to, never lose sight, because when you get really busy and what have you, it’s easy to get in that mode. It’s again, it’s part of being human. I, see how it can happen when, you’re in a fusion center gets just really overwhelmed and really busy with people always keep sight of the human side of your practices. Realize, that’s someone’s mother, someone’s child, someone’s aunt, uncle. And when it gets really busy, I always try and say, use the 20 second rule. Pause. I think everybody can take 20 seconds, no matter how busy you are. 20 seconds, pause, take a couple deep breaths and think about that thought that, what you’re doing is so important. You’re, helping To affect, someone’s again, someone’s aunt or uncle or what have you, this is going to a person and just stay focused on that and then just recalibrate and then get back to what you were doing.
Amanda Brummitt: That’s fantastic advice, Chris. thank you so much for sharing. Your story and your daughter’s story. Thank you for your passion. And thank you for all that you’ve done to make health care safer for all of us because we’re all going to be patients at some point and we all deserve a really safe place to have our care and just really appreciate what you’ve done for that.
Chris Jerry: Well, thank you for this opportunity. Amanda, it’s really been a blessing, for me as well to have this opportunity to share with everyone.
Amanda Brummitt: What an inspiring journey from a tragedy to a foundation that has improved the safety of medication administration through advocacy, legislation, and education. I hope we’ll all remember Chris’s words. You can learn more about the Emily Jerry Foundation at EmilyJerryFoundation. org, and if you aren’t familiar with the WeInfuse software platform and RX toolkit, take a test drive to see how it can save you time and money in your practice while also creating a safer place for infusions. My name is Amanda Brummett, and we’ll catch you in the next episode.
Guest Speaker:
Christopher Jerry is Co-Founder of EJ Health Technologies, a company committed to stopping IV medication errors, and created in honor of his daughter, Emily Jerry, who died of a tragic medication error in 2006.
Chris is also President and CEO of The Emily Jerry Foundation, a non-profit organization that was created and established in 2009. The Emily Jerry Foundation’s primary focus is to reduce and eliminate the number of preventable medical errors. For more information about Chris Jerry and the Emily Jerry Foundation please visit emilyjerryfoundation.org/.
