Karen Berger, PharmD
Karen Berger, PharmD, graduated from the University of Pittsburgh School of Pharmacy in 2001. She has worked in community pharmacies for over 17 years as a Pharmacist in Charge, staff, and floater pharmacist for a large chain. Currently, she is a pharmacist at an independent pharmacy in Northern NJ. She can be reached at email@example.com
About 47% of these tragic medical errors are preventable medication errors, according to Christopher Jerry, a patient safety advocate The second-largest percentage of preventable medical errors is hospital-acquired infections, which account for about 36% of all deaths from preventable medical errors.
Christopher's daughter Emily died tragically as the result of a preventable medical error.
She was the third child in the Jerry family. From the moment Emily was born, she seemed to be an old soul. Emily rarely cried or fussed. She was always giggling, happy, and smiling. Emily was full of life and extremely energetic, an amazing baby girl with a strong spirit. If anyone in her family had a heavy heart about anything, Emily would make them laugh and smile the moment she entered a room.
In 2005, when Emily was 18 months old, she was playing outside with her older brother, Nate, and older sister, Katherine. As Christopher watched them run around and play together, he noticed that occasionally Emily would stop, grab her side, and wince in pain for a couple of seconds before getting back to playing. This happened only a few times that day. Christopher did not think much of it at the time and thought maybe she had just pulled a muscle. That evening though, he discussed it with Emily’s mother, Kelly, and she had noticed it, too. Although they were not worried, they took Emily to a leading pediatric facility in Cleveland Ohio, to get her checked out. There, they gave her a magnetic resonance imaging test.
Up until that point, Christopher’s entire career had been spent in international business in medical imaging, during the transition from analog film-based radiology to the digital realm. He had spent quite a bit of time with many radiology experts in medical facilities throughout Europe and the Middle East. This would prove to be the perfect training for everything that was to come. Subsequently, Christopher agreed with Emily’s physician and thought that the MRI would be the best and quickest way to diagnose his daughter’s problem. After realizing that she had been in the MRI machine for much longer than normal, Christopher began to become concerned. After about an hour, the pediatrician and radiologist came into the waiting room, and Emily's parents knew something was terribly wrong by the expressions on their faces, and they were asked to sit down.
It was then that Emily’s parents received the shocking news that their beautiful daughter had a grapefruit-sized mass, similar to a yolk sac tumor, in her abdomen. The doctors assured the them that it was very treatable and recommended a course of chemotherapy that would require Emily coming in for treatment 3 days each month. The doctors explained that after the chemo finished, there would still be quite a bit of residual scar tissue remaining from the tumor that would then need to be surgically removed. The doctors said that Emily would probably lose a significant amount of weight, exhibit flu-like symptoms throughout her treatment, most likely be vomiting, and would lose her beautiful blond ringlets of hair. They also explained that these effects would be a good sign that the tumor was responding well to the chemotherapy and shrinking in response to the Etoposide.
After her first round of chemo in October, upon returning home from the hospital, Christopher took Emily out of the car seat and expected that she would want to rest, but she immediately ran to the swing set to play. He said that this was further proof of what an incredibly resilient and strong girl she was. Throughout her treatment, Christopher does not remember her vomiting even once. The worst adverse effect was a low-grade fever that was managed with acetaminophen. Emily did not even begin to lose any hair for 3 months, and not only did she not lose weight, she was the facility's first pediatric oncology patient to gain a pound. As a result, by January 2006, the oncology team and Emily’s parents began to worry that the tumor, quite possibly, was not responding to this chemo therapy regimen. With these thoughts in mind, in February, after 5 rounds of chemo, the oncology team decided to run her through the MRI scanner and found that the tumor had not only completely disappeared, there was no scar tissue even remaining.
Everyone was elated about the results, but the oncology team recommended 1 final three-day round of chemo to make certain that there were no remaining cancer cells in Emily’s body that could cause her difficulty later in life. The family began planning a celebratory trip to Disneyland to celebrate her miraculous recovery. Emily’s final round of chemo was scheduled to take place on her second birthday. They celebrated her birthday at the hospital, and dozens of doctors, nurses, and other hospital staff members offered Emily birthday wishes, cards, and cookies. Everything went well the next two days. But on the third day, there was a horrible medication error.
Throughout the chemo treatments, Kelly had always stayed at the hospital with Emily, while Christopher went back and forth between the hospital and taking care of their other children. He had always insisted on being there when the intravenous (IV) infusion was started. As part of standard protocol, prior to the beginning of the infusion 2 nurses would always double-check the IV bag, and then Christopher would triple-check it. On that day, however, Christopher was running a few minutes late because of traffic. When he walked into the room, Kelly was holding an unconscious Emily and had a look of terror on her face. Alarms started going off, and all the doctors and nurses started rushing into the room. Christopher insisted that the IV be shut off immediately. Emily was then rushed to the pediatric intensive care unit (PICU), which happened to be on the same floor as her treatment room. As everyone tried to stabilize her, Christopher was thinking that there had to be something wrong with the IV medication.
With that thought in mind, he went back to the treatment room, dug through the trash and found Emily’s partially full IV bag and told the nurse to call an administrator in charge. Christopher handed the bag to the administrator and said, “This has to be the reason that my little girl is in your PICU. This is where you need to start your root cause analysis.”
They discovered that a pharmacy technician was supposed to use standard 0.9% sodium chloride saline solution, but the pharmacy would periodically run out due to improper “just in time” ordering and inventory practices. The technician did not have the proper training and instead used 3 vials of hypertonic saline (23.4% sodium chloride), filled the bag with these vials, using them as the base solution with no diluent, and then added the etoposide. The pharmacist, Eric Cropp, signed off on it. The hospital pharmacy was extremely busy that day and understaffed. Cropp was struggling with a pharmacy computer system that was down, delayed printing of labels, backed-up orders, and a call to rush Emily’s order. He had asked the technician if she used standard saline, and she thought that she did because she saw “saline” on the vial.
After multiple electroencephalographs over the course of 3 days showed that there was little to no brain activity, Christopher and Kelly were forced to make the worst decision of their lives: to take Emily off life support.
“When you go through something no one should, be the one who still strives to find the good.” – Unknown
After Emily's death, Christopher said that he knew that there was no bringing her back, but he became obsessed with making certain that this type of very preventable tragedy did not happen to anyone else. He had always been religious and felt as if he was being called to make a change. Christopher decided to become involved with being an active part of the solution to preventable medical errors with a strong focus on medication safety. With that core intention in mind, he founded and established the Emily Jerry Foundation (EJF) in 2009. Christopher describes Emily as a little rock star up in heaven and believes that her short life was meant to be the catalyst for positive change, to save tens of thousands other lives.
“The best way to find yourself is to lose yourself in the service of others.” – Mahatma Gandhi
After Emily’s tragic death, Christopher left his previous career and immediately immersed himself in researching medication and patient safety and how to establish a registered 501(c)3 charitable organization. Meanwhile, he was going through a divorce from Kelly and was separated and living in an apartment. One day, Christopher's phone began ringing, with what seemed like non-stop calls from the news media requesting on-camera interviews. He knew that, almost 2 years prior, multiple root-cause analyses, done both by the hospital, and by the Institute for Safe Medication Practices, had showed that there were multiple systems, processes, and protocols that had broken down that horrible day. At that point, Christopher was not aware that Kelly and her family were pursuing criminal charges against Cropp.
Christopher was already completely heartbroken and grieving, not only over losing Emily but also about what appeared to be at that time the complete loss of his entire family. In addition, he also felt badly about previously testifying before the Ohio State Board of Pharmacy against Cropp. For these reasons, Christopher made the decision to completely bow out of the spotlight and decline all interview requests during Cropp’s court proceedings and just watch it unfold in the news media.
What Christopher witnessed from that point forward disgusted and horrified him. In all the media coverage, Cropp was being vilified for Emily’s death and was initially charged with involuntary manslaughter and reckless homicide. As Christopher watched this unfold, he realized that none of what was occurring was addressing the underlying antiquated and broken processes protocols, and systems.
While Cropp was serving his 6 months in jail, Christopher was hard at work at the EJF, learning as much as he could about these types of errors and how to prevent them from occurring in the future. Christopher also had watched “Chasing Zero," a documentary about patient safety that included the incident that occurred with actor Dennis Quaid’s twins and their heparin overdoses. While watching this very important documentary, Christopher noticed that it also included an interview with Cropp from prison. Christopher reached out to the producer of the documentary, Dr. Charles Denham, and they became good friends.
“Let us forgive each other. Only then will we live in peace.” – Leo N. Tolstoy
Later, Christopher expressed regret that he was not there for Cropp during the trial and had left the media spotlight. He worried that these tragedies would continue to occur if this is how our justice system responds, and for that reason, he decided to forgive Cropp on camera and set the record straight. Christopher wanted to put the focus back on fixing and modifying core systems, processes, and protocols in health care. He wanted to make certain that no other family had to go through what his did. Denham was planning a follow-up to "Chasing Zero," called "Surfing the Healthcare Tsunami," and Cropp had just been released from prison. Denham's idea was to bring Christopher and Cropp together on camera for the first time since Emily’s death for a moment of forgiveness. In May 2011, this powerful reunion occurred, and the documentary was aired multiple times on the Discovery Channel.
Afterward, Christopher and Cropp began to extensively travel to medical conferences and facilities all over the country, giving about 10 or 15 continuing education- (CE) and continuing medical education(CME)-accredited lectures and presentations that included their distinctly different perspectives on what happened.
Christopher said that he is a big believer in the adoption and application of "just culture" principles in medicine3 which provide the framework that ensures a balanced accountability for both clinicians and health care organizations that are responsible for designing and improving the overall systems in hospitals. These principles are a way to deal with and truly learn from adverse events and tragedies when they occur in medicine, so that the same types of errors, do not happen to other patients, he said.
“People make errors, which lead to accidents. Accidents lead to deaths. The standard solution is to blame the people involved. If we find out who made the errors and punish them, we solve the problem, right? Wrong. The problem is seldom the fault of an individual; it is the fault of the system. Change the people without changing the system and the problems will continue.” – Donald A. Norman, author of The Design of Everyday Things (Basic Books, 2013)
When a medical error is a result of human error and we vilify the clinician, which has been the predominant response in the culture of medicine over the years, the broken systems never get fixed and even more lives may be lost. There needs to be a determination as to whether there was human error or if someone purposely deviated from protocol (ie, if a clinician was counseled not to do something and then kept doing it and something tragic occurred, then there should be punitive measures taken). On the other hand, when a flawed system sets the clinician up to fail or increases the probability of human error during the treatment, then that clinician needs to be engaged and work with the team to be a part of the solution to assist colleagues in learning from the event and fixing that inherent flaw. Just culture creates a culture or environment in health care that encourages clinicians to speak up and report errors. Some facilities have “good catch programs” established, where health care workers are even rewarded with gift cards or plaques for catching errors before they reach the patient.
Shortly after his daughter’s tragic death because of a pharmacy technician compounding error, Christopher learned that techs are responsible for compounding virtually all IV medications in all our nation’s medical facilities. And that is when he became extremely concerned that the only requirement to become a pharmacy technician in Ohio in 2006, the year Emily died, was that a tech have a general equivalency diploma. There was no oversight provided by the Ohio State Board of Pharmacy.
Upon learning this, Christopher became horrified with the notion that, quite possibly, improperly trained techs were routinely compounding IV medications going directly into people’s circulatory systems. As a result, in 2009, he was pleased to help get Emily’s Law passed and signed into law by Ohio Gov. Ted Strickland. Emily’s Law now "require(s) that 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, criminal records and approved disciplinary actions."4
Prior to Emily’s Law being passed, former Rep. Steven LaTourette (R-Ohio), had introduced Emily’s Act (H.R. 5491) on February 26, 2008, to Congress. Unfortunately, it was not passed by the House because of concerns about federal versus state enforcement issues related to this type of legislation. This is when Christopher came to his obvious next conclusion: that to advocate for positive change with respect to tech oversight on a national level, he would have to begin the long and arduous task of approaching individual state legislators on a state-by-state basis.
This was the underlying motivation behind the whole idea for the EJF’s National Pharmacy Technician Initiative and Interactive Scorecard, he said. In 2011, Christopher approached the American Society of Health System Pharmacists (ASHP) in Bethesda, Maryland, to see if its leadership liked the idea and if they would be willing to develop the scoring criteria and provide assistance with this enormous undertaking. ASHP was extremely interested and immediately made the decision to assign a team of people to work on this with him. Because of this partnership that continues to this day, this key initiative for EJF was introduced in 2013. This interactive scorecard of the United States is where clinicians and patients can see exactly what kind of legislation is in place for techs in the states where they practice medicine or reside. Click on a state to see the scorecard and the different categories of criteria and grading. ASHP’s legal team also provides the corresponding legislation that is unique for each state related to techs.
Over the past decade, Christopher has worked almost exclusively with clinicians themselves to affect positive change in how we respond to and learn from preventable medical errors. Over time, he has realized that clinicians share his concerns. Whether we work in a community or hospital pharmacy, we are all at risk of making an error that reaches the patient. Christopher knows that this is our biggest fear, what keeps us up late at night, what makes us call our partners after work, asking them to double-check something. He advocates not only for patients but for clinicians as well. Christopher thinks that clinicians are compassionate, well-intended, and want to help people. He focuses on learning from every intricate detail of an error when it occurs. Where did the holes in Dr. James Reason’s “Swiss Cheese Model” line up when an unintended error occurs?5
Where did the processes, protocols, and systems break down? We owe it to Emily and the thousands of people who die every year to learn what happened and go back and fix the broken system so that others do not die the same way. What causes the holes in the Swiss cheese to line up? Most of the time, it has been Christopher's experience, that it is typically not someone even deviating from a set protocol. He believes very strongly that most errors are a result of the inherent human error component of medicine. We are all capable of making a mistake that can reach a patient. Human error can enter a pharmacy workflow whether in a community or hospital pharmacy.
Christopher gives many CE- and CME-accredited lectures and presentations around the nation for many health care conferences and organizations. At every speaking engagement, he always stresses the importance of us all being aware and focused on the significance of the human error component. Christopher's ultimate goal is to get to 0 preventable medical errors overall. In his opinion, just 1 life lost to preventable medical error is 1 too many. Although Christopher realizes that this is an extremely audacious goal and may take many years to accomplish, he is also very honest about sharing his more realistic goal, which he feels can be accomplished in his lifetime, which is to get close to 0 preventable medication errors.
Over the past decade, he has always believed in the smart adoption and implementation of clinically proven technology as the way to eradicate this inherent human error component. Along those lines, Christopher also said that for these proven tools to be truly effective in saving lives, they absolutely must be coupled with new and improved, and ever-evolving best practices, as they are developed by the experts in the individual modalities such as pharmacy.
At the 2017 Pharmacy Technician Stakeholders Consensus Conference in Texas hosted by ASHP and the Pharmacy Technician Certification Board, there was much discussion about the basic qualifications related to pharmacy technicians, whether in a community or hospital pharmacy. The objective of the conference was to reach consensus on what core qualifications are shared.
In his keynote address, Christopher shared an analogy that was instilled in him very early on by someone he considers a mentor, ISMP President Michael Cohen, RPh, MS, ScD (hon.), DPS (hon.). Cohen told Christopher that the pharmacist is always the coach, while the techs are always the team. What coach does not want the best team, and what team does not want the best coach?
Cohen went on to tell Christopher that there is not a pharmacy on the planet that could operate safely without career-oriented, competent, and well-trained techs. Although their scope of practice has significantly expanded and evolved over the years, Christopher thinks that all too often they are still many times treated as low-cost, unskilled, hourly labor and that techs should be treated with the respect that they deserve in terms of their overall scope of practice and the vital role that they all play as the “team” members in overall medication safety in pharmacy practices.
As he is starting to become more and more involved in retail pharmacy, Christopher wants to see the pharmacist “coaches," along with their tech teams, rally together to prevent medication errors and subsequently improve overall medication safety in the community pharmacy. How do we do this? Here are a few of Christopher's suggestions:
- Be proactive and hypervigilant about where human error could creep into the pharmacy's workflow and address it accordingly by modifying core systems, processes, and protocols.
- Community pharmacies should maintain a high-alert medication program, combining on-screen alerts with shelf stickers that help reduce the risk of look-alike and sound-alike errors.
- Conduct a routine and systematic medication audit and reconciliation for ALL prescriptions filled by each pharmacy daily. Focus on misfills, potential drug interactions, etc. This can be costly and time consuming, but many errors can be quickly uncovered, and patients can hopefully be contacted before harm occurs.
- Track and report all errors that occur, internally and according to requirements set forth by the state boards of pharmacy. When errors do occur, pharmacy leadership on all levels, including upper level business management, have an obligation to patients. They must take corrective measures and learn the intricate details associated with each error and then go back and modify core systems, processes, and procedures, so that the same errors do not reoccur repeatedly.
Christopher strongly expressed his feeling that Emily is not just his guardian angel but all of yours, too. I think all pharmacists and techs should keep Emily and others who die every day due to preventable medical errors in their hearts and minds every day as we all strive to do better.
1. James T. A new evidence-based estimate of patient harms associated with hospital care. Journal Patient Saf. 2013;9(3):122-8. doi: 10.1097/PTS.0b013e3182948a69.
2. Makary MA, Daniel M. Medical error—the third leading cause of death in the US. BMJ. 2016;353:i2139. doi: 10.1136/bmj.i2139.
3. Center for Patient Safety. Just/accountable culture. centerforpatientsafety.org/just-culture/. Accessed February 14, 2018.
4. Wikipedia. Emily's Law. en.wikipedia.org/wiki/Emily%27s_Law). Accessed February 14, 2018
5. Raheja D, Escano MC. Swiss cheese model for investigating the causes of adverse events. Journal of System Safety. system-safety.org/ejss/past/novdec2011ejss/healthcare_p1.php. Published November-December 2011. Accessed February 14, 2018