There is no greater pain than the loss of a child. It is a degree of suffering that is impossible to grasp without experiencing it first-hand. And this type of grief often lasts a lifetime. Christopher S. Jerry, Founder and CEO of the Emily Jerry Foundation, understands the depth of this pain, having had to come to terms with it following the tragic event that took his beautiful daughter’s life. Referring to himself as a ‘survivor,’ Jerry recounts the experience of losing Emily, his third born child due to a combination of healthcare system failures and human factors at a leading pediatric facility in Cleveland, Ohio. Errors that resulted in the loss of his beautiful baby girl, that were very preventable.
Jerry’s immediate concern following Emily’s death was never to blame or take retaliatory action against the esteemed medical facility that was responsible for the fatal dose that killed his child. In fact, he is very quick to explain that what often gets lost in Emily’s tragic story, is that it was at this hospital, with all of the wonderful care that was provided by the clinician caregivers that had actually cured his little girl. Instead, Jerry worked long and hard to figure out where the underlying systems, processes, and protocols, broke down in Emily’s care that set her amazing care team up for failure. Jerry was horrified with the thought that if he didn’t learn where the systems broke down that horrible day, other babies and children would be put at risk of losing their lives the same exact way as Emily. As a result, Jerry has committed the remainder of his life’s work to finding comprehensive ways to reduce the inherent “human error component” in medicine. Subsequently, he hopes to save countless lives by eradicating medication errors forever, which are currently estimated to be the largest percentage of preventable medical errors overall (approximately 43%).
“I was horrified with the thought if we didn’t learn exactly where the systems broke down and they were never modified, my worst fear became turning on the television in the morning, drinking my coffee while watching the news and learning that another baby had tragically died the same exact way my daughter did.”
Emily Jerry, a bright-blue eyed girl with beautiful blond ringlet curls, could light up a room with her smile. She lived two years before her life was cut irreversibly short because of a preventable medication error. Emily was diagnosed with an abdominal tumor when she was one-and-a-half years old and while this form of cancer was terrifying for her loved ones, Emily’s doctors were confident that her cancer was not only treatable, but curable. In the proceeding months that followed her diagnosis, Emily began her chemotherapy regimen which required her to spend three days each month at the hospital. Yet through trying times, Emily danced through her treatments and maintained her contagiously bubbly and cheerful demeanor.
After six months of chemotherapy, Emily’s final MRI showed no further trace of the tumor in her abdomen. The tumor, which initially had been the size of a grapefruit, had completely disappeared. The MRI results also revealed that there was no residual scar tissue left, it was as if Emily had never had cancer. Her care team was floored. A miracle had taken place.
Despite this amazing prognosis, Emily’s doctors recommended one final three day round of chemotherapy to make absolutely certain there were no remaining cancer cells left in Emily’s body that could emerge later in her life causing her difficulty. Emily’s parents decided to schedule this final three day round of chemotherapy to begin on Friday February 24th, Emily’s second birthday. As Emily’s parents, Jerry explained that they felt that this year, what could be a greater gift than Emily finally coming home on Sunday, cancer free, and celebrating her miraculous recovery at home as a family?
Unfortunately, rather than the Jerry’s taking their baby girl home cured, the unintentional fatal dose was administered that Sunday afternoon on February 26th, two days after Emily’s second birthday. The clinical pharmacy at the hospital that day ran out of standard bags of saline with 0.9% sodium chloride. Subsequent root cause analysis found that a pharmacy technician had taken an empty compounding bag and filled the bag with three vials of hypertonic saline, with a 23.4% concentration of sodium chloride, and used that as the base solution for Emily’s chemotherapy that day. That lethal injection of a salt solution came with a cost, Emily’s life. Emily died three days later.
Following Emily’s tragic medication error, Jerry identified where and how the human error occurred and, subsequently, found clinically proven solutions to prevent this from ever happening again to others. Since his daughter’s tragic death 11 years ago from a preventable medication error, Chris began this unintentional quest, chosen for him, to work diligently to affect positive change in medicine. Consulting with the brightest minds in healthcare, he has helped transform the culture of medicine, how it is practiced in the U.S., and more importantly how we respond and learn from these preventable errors.
He established the Emily Jerry Foundation, a 501c3 non-profit, to be an active part of the solution to preventable medication errors. The Emily Jerry Foundation’s simple, yet effective tagline – “For patient safety and safe medication practices,” leaves no doubt about the Foundation’s purpose, mission and commitment.
Since 2006, Chris has been submersed working with the leading medical technology innovators and healthcare providers to discover effective technologies and solutions that are proven to save lives. Jerry’s advocacy efforts led to the passing of an Ohio Senate Bill in 2009 also known as, “Emily’s Law, “which provides comprehensive oversight of pharmacy technicians by the Ohio State Board of pharmacy. Prior to the passage of Emily’s Law, the only requirement to become a pharmacy technician in Ohio, was that a person had their GED, and there was absolutely no oversight of pharmacy technicians whatsoever. After the passage of Emily’s Law one of his primary goals and objectives was to have a more comprehensive version of Emily’s Law to be in effect across every state. To accomplish this life saving goal, the Emily Jerry Foundation, in conjunction with the ongoing partnership with the American Society of Health System Pharmacists (ASHP), EJF launched its National Pharmacy Technician Initiative and Scorecard which was designed by ASHP to grade every state on the strength of its technician requirements and regulations. Ever since the introduction of this very important initiative in 2013, Chris has been working with the individual state boards of pharmacy to affect positive change, helping to be their voice with the state legislators, testifying at countless State Senate Health Committee Meetings, and most importantly helping a number of states to improve their scores overall.
Tragedies like Emily’s emphasize the dire need, after preventable medical occurs, for the focus to be put on modification of systems, processes, and protocols, in medicine in order to prevent and mitigate the impact of medical errors.
“Emily’s story is emotionally upsetting for all of us because it brings to light the human side of and healthcare, that we all can relate to, and all of the great work that’s currently being accomplished from a clinical perspective. What get’s lost in Emily’s tragic story sometimes, is the fact that it was not only by the grace of God first and foremost, it was modern day medicine that had actually cured my baby girl, nobody meant for this horrific tragedy to happen.”