Transcript of Podcasts #203 & #207 – Chris Jerry, The Emily Jerry Foundation

LeanBlog Podcast #203

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Listen to the episode while reading:

Announcer:  Welcome to the Lean Blog Podcast. Visit our website at www.leanblog.org. Now, here’s your host, Mark Graban.

Mark Graban:  Hi. This is Mark Graban. Welcome to episode 203 of the podcast for June 23rd, 2014. My guest today is Christopher Jerry. Chris is founder of the Emily Jerry Foundation. You may have read about this on my blog previously.

The foundation was created, sadly, in the aftermath of the tragic death of Emily Jerry, Chris’ daughter, a few years back; a preventable medical error that was caused by a number of factors and bad systems.

I really admire that he’s been able to channel his emotions in the aftermath of losing his little girl into this advocacy for others, creating a foundation, telling a story, and I think more importantly, emphasizing the need to not just blame and punish individuals, but to focus on improving symptoms, improving processes, that that’s the best way of protecting other patients and doing so as a way of honoring Emily and her tragically short life and her memory.

This is going to be a multiple part podcast series, and this first part today, we really don’t get beyond the story of what happened and the reactions and the aftermath to that. I’m going to do either one or two more parts, taking the remaining audio and the rest of our discussion and release that as one or two more podcasts, depending on how that divides up.

I certainly encourage you to go to Leanblog.org/203. You can find links to the foundation website. You can read more background, see some videos of Chris and Eric Cropp, the pharmacist who was blamed and punished and convicted and jailed for his parts or for being there when this tragedy occurred. It’s a gripping story.

I hope you find it interesting and inspiring and that you’ll want to do more to help, whether that means helping the foundation or helping share Chris’ work and story. This is powerful stuff. Thank you for listening. If you want to subscribe and make sure you learn about the future episodes, you can go to Leancast.org.

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Mark:  Chris, hi. Thanks so much for being a guest on the podcast to talk about this incredibly important topic today. Thanks for being here.

Chris Jerry:  Thank you for having me, Mark. I really do appreciate the amazing work that you’re doing in the area of Lean and how it can possibly affect these issues relating to preventable medical error and drive things forward in a very positive way.

Mark:  Thanks. You’re too kind. There’s so many of us in the Lean community who are trying to help people improve quality and patient safety. A lot of inspiration comes from stories like yours and Emily’s for those of us who haven’t been touched directly, ourselves or our families, by preventable medical error.

I appreciate you sharing your story and working so hard to be able to help others. A lot of our listeners might not be familiar with your story and Emily’s story. If you wouldn’t mind just starting off by telling that first.

Chris:  Definitely. My name is Chris Jerry. I’m a very proud father of three amazing children. I’m stating the obvious here, Mark, but I’m one of those individuals that believes every child born into this world is truly a miracle. They all deserve to be treated as such.

With that said though, my other two children, Nate and Catherine, are just incredible blessings. What I want to say, without showing my other children or any other children, for that matter, any disrespect is the fact that Emily, from the day she was born, seemed a little different than my other two.

Right from the start, I don’t know how else to describe it other than to say her mother and I used to refer to Emily as being an “old soul.” She seemed to know a little bit more than my other children did. She was unique in the other sense that she was always so happy.

She didn’t fuss like normal children do. You couldn’t be sad around Emily for more than a nanosecond or two. We could be upset as a family about something, and Emily would come strolling into the room just like laughing and giggling and what have you, and all of a sudden, your biggest problems as a family seem so miniscule. It just seemed to be a gift of hers. She had a very vibrant spirit is what I’m trying to express and very, very energetic.

During the summer of 2005, Mark, Emily was playing out in the backyard with her big brother and big sister, Nate and Kathryn, and they’re running around, a beautiful late summer day. Every once in a while as I’m watching them from the upper deck run around the backyard and play around on the swing set and things like that, I noticed Emily, every once in a while, would stop and grab her side and wince in pain.

Again, being the strong little girl she was, that would last all of a nanosecond, and she’d be right back to doing what she was doing. Maybe because she was our third child, Mark…with your first baby, you worry about every little sniffle and sneeze, and you think, OK, my son just sneezed, I’ve got to run him to the ER, he’s got some horrible virus or something. You’re a little paranoid with your first.

With Emily, I wasn’t too worried about it. I just witnessed this happen maybe three or four times over the course of an afternoon, and I thought to myself, there’s something going on there. She’s showing that she’s a little uncomfortable and in a little bit of pain every once in a while. I discussed it with Emily’s mother, and we both thought, OK, the next day, we’re going to take her over to a leading pediatric hospital here in Cleveland, just have it checked out and just to try to find the source of Emily’s discomfort. We brought her in, Mark, in the early fall of 2005 to have her checked out.

They decided to run Emily through the MRI to see what was going on. My whole career had been spent in medical imaging, working with the manufacturers of those systems, things, and so naturally, I’m thinking to myself, “Boy that sounds like the most reasonable course of treatment right now to try and find out what the source of the problem is,” they run her through the MRI.

They did that, and lo and behold, it was discovered that Emily had a grapefruit size mass growing very rapidly in her abdomen. It was the most shocking news that any parent could ever imagine, especially, when little Emily outwardly didn’t appear to be sick in any way, shape, or form. She looked to be a completely healthy little girl.

The decision was made pretty much immediately that the course of treatment for Emily…they assured Emily’s mother and I that even though it was so large, it was very treatable. It was very similar to a yolk sac tumor. They told us that we would need to bring Emily in for about three days each month for routine chemotherapy and then after five or six months of treatment, that Emily would probably need to have surgery to remove any residual scar tissue that would remain from the tumor with that type of size.

We embarked as a family on this very scary road, and the pediatric oncology team set our expectations as Emily’s parents as to what to expect. They told us, “Little Emily is going to lose all of her beautiful blonde ringlets of hair. She’s going to lose a significant amount of weight.

Especially, right after the three day rounds, she’s going to be exhibiting flu like symptoms. She’s going to be vomiting and all of that.” But, not to worry because that is just going to be a very good sign that the tumor is actually responding to the chemotherapy.

Mentally, Emily’s mother and I moved forward with those kind of expectations. Mark, we brought Emily home from her first three day round of treatment, and I’m going to take Emily out of her car seat at the top of our driveway and bring her inside, and as soon as I take her out of her car seat, that little girl’s running towards the darn swing set immediately.

What toddler wouldn’t after being cooped up in the hospital, right? My point was is I don’t think, and I know I’m bragging a little bit here, Mark, I think it’s warranted, that my little girl, Emily, vomited one time after a chemotherapy regimen. She didn’t start to lose her beautiful blonde ringlets of hair until about January of 2006.

I’m very proud to say I was told by her pediatric oncology team that…This is at a facility that has roughly 450 beds, a pretty large children’s hospital. I was told that Emily was their first pediatric oncology patient that actually didn’t lose any weight during the course of her treatment. My little girl somehow, someway, actually gained a pound during the course of treatment.

Naturally, January, February rolls around. During her treatment, I started to think to myself based on what I had been told previously, I started to think to myself, “Maybe that tumor is not responding to the chemotherapy treatment.” Emily’s oncology team thought the same thing.

They run her through the MRI again in the beginning of February in 2006, and lo and behold, their words, not mine, Mark, “A miracle had occurred.” That miracle that had occurred was that not only had the tumor completely and totally disappeared, but there wasn’t even any residual scar tissue remaining from that tumor, from that mass being so large.

We were all elated. That’s the kind of miraculous outcome, again, their words, not mine, that I would think every caregiver that gets involved in a career in healthcare would want to experience at least once or twice during the course of their lengthy careers.

Her oncology team, everybody…everybody at this facility, Mark, I have to say to our listeners, every caregiver…I told you what kind of background I came from. My whole career was spent being on the business side of medical imaging and being in and out of hospitals throughout Europe and some in the Middle East and things like that. My expectations when Emily was first diagnosed were probably a little higher and a little on the obnoxious side when it came to…

Mark: In what way?

Chris: When it came to what kind of expectations I had for the care that my daughter was going to receive when we started the treatment. I have to say, and this is why I consider myself a very proud patient safety and caregiver advocate, it’s because every caregiver that came in contact with my daughter from day one loved my little girl up like she was their own and exceeded my very high expectations for the care that my little girl was going to receive.

That’s why I think ultimately, in large part, that’s why I think my daughter had overcome this horrible affliction.

Mark: I think we’re in agreement. A lot of the listeners would agree as you talk about what then happened that none of this is a “bad apple” problem. I appreciate that you’re expressing your gratitude and respect for all the great individuals who were involved in that care.

Chris: Yes. Mark, to speak to what you just said, what I’m trying to do is paint the picture here because everybody was so elated, not only we, as parents, and as an extended family were happy with this outcome, the caregivers, all were very proud, as they should’ve been, of what had been accomplished with little Emily. I’ll never forget, Mark, that Emily’s mother and I are seated then with the oncology team after they ran her through the MRI in the beginning of February, and they’re all happy as can be.

All of a sudden…Initially, when you’re given that kind of news, I’m thinking, “OK, we can dress my little girl up and bring her home,” and they all immediately said to Emily’s mother and I, “We’re going to recommend…this is happy. You guys can begin your plans for taking the family to Disney World and things of that nature to celebrate Emily’s recovery, but we’re going to recommend one final three day round of chemotherapy just to make sure that, make certain, make absolutely 100 percent certain, that there are no residual cancer cells remaining in little Emily’s body that could pop up later in life and cause her difficulty.”

Naturally, Emily’s mother and I agreed to do that. We brought Emily in on…because we wanted to get this put behind us and move on as a family, we decided to bring Emily in on February 24, 2006, which was a Friday, and that happened to be Emily’s second birthday. I couldn’t think to myself of a better birthday present to any child than knowing in the back of my mind, I’m going to be bringing her home cured. We actually celebrated Emily’s birthday at the medical facility that Friday.

We actually brought in cupcakes and what have you. By now, word had traveled throughout this 450 bed facility to the other floors and things, to all the caregivers and what have you, about Emily’s miraculous recovery.

Mark, in my younger years when I used to go to them, I swear I used to see shorter beer lines at rock concerts with respect to all the caregivers from these other floors that had never met Emily that wanted to come down and say, “Happy birthday,” to her and give her small birthday cards and little gifts and treats and just spoil her up a little bit. It was amazing. Everything went well later that day with Emily’s first day of her last three of the chemotherapy regimen. Everything went fine.

And then, on Saturday everything went fine, as well. On Sunday, Mark, is when the nightmare began to unfold. I had arrived. I was taking care of my other two children at home. I had arrived at the medical facility about 10 or 15 minutes after they had started Emily’s IV.

When I walked into the treatment room that day, my wife was holding Emily unconscious in her arms. I looked at her and I still remember this, Mark, in very slow motion because it was just so shocking. I looked at my former wife. Looked her in the eyes and I said, “What’s going on? What’s wrong with Emily?”

She just gave me this blank stare and shook her head and I saw total fear in her eyes. I say I remember it in slow motion because it seemed like it was forever but in that same fraction of a second, immediately all the alarms were going off and then the nursing staff and the physicians and everybody were rushing into the room.

We all took Emily from Kelly’s arms and put her on a gurney together. Everybody’s trying to figure out why did her condition deteriorate so quickly. They’re trying to stabilize her. They obviously shut off the IV and were trying to get Emily to regain consciousness. We all rushed Emily down to the PICU, the pediatric intensive care unit which was on the same floor as Emily’s treatment room.

They subsequently induced Emily into a coma. As the doctors and specialists are trying to assess what had happened to Emily I was just sitting there with Emily’s mother, trying to figure out what the heck happened here. She was just fine a day or two ago and now my little girl’s in your PICU induced into a coma. It’s not rocket science, Mark, but I came to the conclusion rather quickly that it had to be something relating to Emily’s IV admixture. Had to be.

And so, I couldn’t sit still for very long. I immediately went back to Emily’s treatment room. I had a nurse with me. I immediately started digging through the trash to find Emily’s partially full bag. I did that. I had the nurse call down for a hospital administrator. I said, “Please call the administrator.” She did.

The administrator came up and I handed her the bag and I said to her, “I really, truly believe this is where you need to start your investigation. This has to be the reason my little girl is down in your PICU. It has to be.” That’s where it started.

Mark: Did that administrator respond? Did they respond in a way that took that seriously?

Chris: Yes.

Mark: They did listen to that.

Chris: I have to say, Mark, they did take it very, very seriously. I get asked this question often. I’m a big proponent of transparency when these things occur and to be honest and forthright with people, especially, when it comes to their loved ones. A lot of people asked me, then, subsequently, “Do you feel the facility was being transparent with you because they felt that you found the smoking gun? That just because you dug through the trash and found that partially full bag.”

Mark, I’m of the attitude…I’m always the optimist. I believe this facility was very, very transparent with Emily’s mother and I with their root cause analysis and what had happened and what have you, because it was the right thing to do because they knew they had to do it. I’d like to think that it’s not just because I handed them that partially full bag. That’s the walk that they seem to be walking now, going forward, years after Emily has passed. I’m very proud of them about that fact.

They started the investigation and they found out what had happened, Mark, was that a pharmacy technician who didn’t have the proper training or core competency. We’ll go into that in a little bit. The clinical pharmacy had been out of standard bags of saline with .9 percent sodium chloride. In being out of standard bags of saline, the pharmacy technician who was on duty at that time thought that she was doing the right thing. I really believe that she did think she was doing the right thing.

She saw three vials of what’s called hypertonic saline, which has 23.4 percent sodium chloride in concentration, which is just meant for small boluses or amounts to be added to people that are a little bit dehydrated, that need electrolyte replacement, and things of that nature.

She sees these three vials and she thought she was doing the right thing. She grabs an empty compounding bag and then manually extracts these three vials of hypertonic saline, 23.4 percent concentration, and fills the bag full of this hypertonic saline and then added Emily’s chemotherapy agent to that. She even made the mistake of, as I understand it from talking with Eric Cropp, the pharmacist involved, that she had hand labeled that bag with .9 percent sodium chloride, the correct concentration, which is why Eric signed off on it that day.

It gets sent up to Emily’s room and the reason Emily was unconscious when I arrived at the hospital 10 or 15 minutes after they started the IV was, because when somebody is overdosed on something as simple as a common electrolyte like sodium chloride, salt, it causes immediate cerebral edema or brain swelling. Emily had actually gone unconscious, passed out, due to the pain that was involved. Not to paint an even more tragic picture, but I want our listeners to know what happens.

Mark: If anyone would think, “Oh, it’s just saline.” No, that has horrible consequences.

Chris: In fact, sodium chloride is, what I’ve learned since I began doing this work in patient safety and working with groups like the Institute for Safe Medication Practices, ISMP, and the American Society of Health System Pharmacists.

From the pharmacy experts what I’ve learned is that common electrolytes like sodium chloride, salt. Things like potassium. They’re considered in the clinical pharmacy very high risk medications that need to be kept under lock and key, because things like potassium are what are used, I guess, when they’re doing capital punishment, where they’re executing somebody. They use potassium to stop a convicted person’s heart. In high concentrations, if accidentally given to a patient in too high of a concentration these are medications that actually can really, really harm people.

Mark: In the course of that happening, I was jotting some things down here. At least four different things that I would consider systematic errors. You mentioned the lack of training and credentialing. Being stocked out of the standard bag of saline. Thinking she was doing the right thing.

That points to either, again, lack of training, lack of supervision, lack of a culture where people can speak up and say, “Hey, wait a minute. We don’t have the right bag. What do you expect me to do?” The labeling error. It seems like a litany of systematic errors.

Chris: Correct. You are spot on there, Mark, because what I was horrified to find out…A few weeks later is when the root cause analysis study, a very comprehensive one, was completed. The facility sat down with Emily’s mother and I and were very transparent about exactly what had happened.

First and foremost, I have to say before I go there, three days after Emily was overdosed and induced into coma after multiple EEGs showed little to no brain activity.

Emily’s mother and I had to make the worst decision of our lives which was one that I hope none of our listeners ever have to make for any of their loved ones.

We had to make the decision to take Emily off of life support. That day, and Mark, I know you’ve seen some of the videos and some of my presentations. It’s true.

That day was the only time in my life that I had contemplated doing something incredibly stupid. I had been loading some of Emily’s personal belongings into our SUV, that day, which was parked on the top floor of the parking garage.

I saw Emily’s car seat, in that car, as I was loading her things, just so confused and so emotionally traumatized as her father, thinking to myself, “Hey, I was supposed to be taking my little girl home today and now I’m not. My little girl’s gone to the morgue.” I didn’t understand.

It was at that moment that I felt that it was by the grace of God and by my little girl’s spirit that they were hitting a pause button for a moment. All of a sudden, I started thinking rationally for a second because I was thinking, Mark, maybe I should go take a flying leap or join my little girl.

All of a sudden it was like, “No. You need to find out. Daddy, you need to get to the bottom of this, what set these wonderful caregivers up to fail me? You’ve got to make sure that those systems and things are modified, accordingly, so that it doesn’t happen to other people.”

A lot of people asked me, “Chris, when did you decide that this was going to be your calling, this was going to be your life’s work, this is what you’re going to do”? It was at that point. I knew immediately that this was the work that needed to be done. After we had the root cause analysis with the facility, where they were very open and transparent with us, they told us it was a pharmacy technician error.

Naturally, the next question in my mind was, “Wait a minute, here. I would think that going into any major medical facility is going to be giving you IV medications which are most all of them when you go in for care.” A lot of times they’ll give you medications just to keep you hydrated. I started researching immediately. I thought it would be a pharmacist that would be compounding everything going right into someone’s circulatory system.

Mark: Right. Let me ask you another question. You talked about the root cause analysis. Did the hospital show an appreciation for the systemic factors including, if I remember correctly, there’s discussion of being overworked and understaffed, or other issues. Did they have an appreciation for that, or did they say, “That person made a mistake”? Or is it all of that?

Chris: It was all of it together. They were all shocked, themselves. That goes back to the human nature side of things. Whether they said it or not, they did point the finger initially. I didn’t find out about this until afterwards.

I’d always wondered, in my mind, why didn’t the pharmacy director or the pharmacist that was involved that signed off on it immediately come up to the peak view that day and just say, “Hey, we’re sorry. We’re looking into this. We don’t know what happened yet, but we’re looking into this. We’re also deeply disturbed by the whole thing.”

That never happened and I never realized this. One of that ways that they pointed the finger, whether they said they did or they didn’t, was by, just two days later, they called Eric Cropp and the pharmacy technician, and asked them to come in.

Mark: Eric was the pharmacist who signed off?

Chris: Yes. Eric was the pharmacist involved and Katie Dudash was the pharmacy technician involved. They call them in and, immediately, they fired them. They just told them to get their things and leave.

Mark: Was this before the root cause analysis was done?

Chris: Yes.

Mark: That probably wouldn’t get done in two days.

Chris: Right. The way that Eric had to learn about Emily’s death was by one of his colleagues calling him up after he had been fired and saying, “Little Emily’s passed away.”

Imagine how traumatic that was for them, being the second victims. To have to learn of it that way but to, also, initially have the finger pointed at you, hear you’re being fired before root cause analysis has even been done. I believe that it’s because the facility may not have had, I believe that they didn’t have, anything that even looked like the Just Culture Principles that you and I are big proponents of, in place, they didn’t know how to respond.

Mark: I think it’s tempting by human nature, not just to blame but to say, “We took action. We held someone accountable. We fired two people.” Even to public perception, a lot of people who don’t think about the systemic causes of problems, “You did something.”

Chris: Right. You responded to it and I think it’s human nature. When something horrible or tragic happens, it’s part of the human nature, the human condition, at least for a short period of time, for all of us to think to ourselves, no matter how rational you may be, for a moment at least, “Who is the SOB responsible? Who is that person”?

We need to find this culprit. It’s part of the human nature, to think of this stuff in the back of your mind, that not only will you need to find this person and associate to blame, but we need to effectively have a public lynching, somehow, someway. That’s exactly how I viewed things in terms of how they happened with the pharmacist that was involved, Eric Cropp.

When, in fact, we find out that, I think this is what separates people when these tragedies occur, is how long you have those thoughts for. After root cause analysis has identified multiple systems failures, processes, and protocol failures, if you follow through and you do have the public lynching, and you do associate the blame with that individual, is anyone being made any safer? Are those systems and processes being modified accordingly so that those same errors don’t happen over and over again?

Mark: That was part one of my discussion with Chris Jerry. I hope you will come back and hear the remaining part of the discussion. You can go to leancast.org if you’d like to subscribe or go to leanblog.org and sign up for email notifications of new blog posts, including these podcasts.

We’ll hear the rest of the story where we’re going to talk more about what’s happened in the Patient Safety Movement, what the foundation is doing, and what people like Chris are doing to try to help prevent tragedies like this from occurring with other families and other children. Thanks for listening. You can go to http://www.leanblog.org/203 to find links to stories. You can read online videos or things like that if you’d like to dig deeper into what’s happening here. Thanks for taking the time to listen.

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Announcer: Thanks for listening. This has been the Lean Blog Podcast. For Lean news and commentary updated daily visit www.leanblog.org. If you have any questions or comments about this podcast, email mark at [email protected]

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Transcription by CastingWords

LeanBlog Podcast #207

Check out the page for this episode with links and more information

Listen to the episode while reading:

Mark: I think a key of this systemic view is to look and say, well, would a different pharmacist not named Eric Cropp, who by luck of the draw would have happened to have been working that day, also seen that bag? Also signed off? Also ended up in the same situation? Probably, right? He didn’t have super-human abilities to look at that bag and see the concentration of saline.

Chris Jerry: Precisely.

Mark: That’s just not possible.

Chris: Precisely. I do agree completely, Mark, because I’ve applied those scenarios as well in my mind. I really do believe that even if you were able to gather up 6, 10 of the leading rock star pharmacists at that given point around the nation.

Put any one of those in that same environment that day, and they would’ve made the same decision [inaudible 02:52] that bag.

I was given the opportunity, Mark. A few years after Emily had passed, I’d been going through a horrible divorce, I know that they all are, but my former wife and I were separated.

I wanted to persevere with respect to my patient safety advocacy efforts and with the establishment of the Emily Jerry Foundation.

As I’m doing this work to establish the foundation and just try to gather as much knowledge as I could about patient safety and preventing these types of horrible tragedies like what occurred with my daughter from happening to anyone else.

I was going through a horrible stage of the grieving process even though I think it was also miraculous, Mark. I say this all the time.

A lot of people who ask me, “Chris, when you were standing on that parking garage, weren’t you just mad as hell at the caregivers? Weren’t you mad as hell at the facility where it happened?”

The honest answer to that is “No.” I was emotionally traumatized, I always will be, I continue to be as would anybody. Like I said, it truly is a miracle that I skipped over what I think is like the second phase of the natural five steps of grieving, which is anger.

I think the reason I wasn’t angry was because of the way that the caregivers had taken wonderful care of my daughter and because effectively what gets lost in this tragic story with Emily quite often is the fact that modern day medicine cured my little girl of a grapefruit-sized mass in her abdomen.

Cured her, none of us can forget that, and that’s why I still, to this day, have the utmost respect for modern day medicine.

Today is because we are now curing various forms of cancer and different diseases that just 10 years ago would’ve been terminal, would have been an immediate death sentence.

Mark: Right.

Chris: We now have documented cases of people overcoming even stage IV cancer of different types.

Mark: Yeah, a good friend of mine is in that camp and is a patient advocate for different issues.

You’re right, there are amazing things that happen and at the same time. Just purely just preventable headshaking, anger inducing, sadness inducing errors that are occurring each and every day multiple times a day.

It’s not meant at all to diminish the first victim, your loss, Emily’s life being stolen from her, and her being stolen from you and the rest of your family. To think about what’s fair for those who were “involved in the incident.”

That might just sound like, “passive phrase, passive voice,” but it’s probably more accurate than saying the person who screwed up, the person who’s involved in that error, what’s fair for them, an error crop, I don’t know how much you want to talk about the trial or the aftermath, but what happened with Eric.

Chris: My point there, Mark, and multiple things come to mind, but the biggest thing is what was most important to me was I knew I couldn’t bring my little girl back, however, I still feel and I am very outspoken about it, but I still believe that little Emily is still with me.

She’s not just my guardian angel, she’s everyone else’s. My point is in expounding on everything I just aforementioned was the fact that I knew right from that point the day we took Emily off the life support that I wanted to be engaged in being a part of the solution to preventing it from happening to others.

Immediately after root cause analysis, Mark, I began researching and doing my homework about what did you need to do to become a pharmacy technician in the state of Ohio.

At that time, the only requirement in 2006 to become a pharmacy technician and start routinely compounding IV medications, which by the way most of our public is not aware that in all of our nation’s medical facilities, pharmacy technicians compound virtually all, and those words are not sensationalized at all.

You ask any pharmacist that’s been in clinical pharmacy, who compounds virtually all IV medications like they will tell you a pharmacy technician. The only requirement to become a pharmacy technician, in 2006 in Ohio, was that you had your GED.

The barber cutting my hair in 2006 had to have their cosmetology license displayed next to the barber chair. And show before they could legally cut my hair that they had 6 to 12 months, I forgot what it is, of full-blown cosmetology school and that they passed all their tests before they could legally cut my hair.

Yet somebody that’s compounding IV meds going into my children’s circulatory systems directly, they just had to have their GED.

Mark: Right. We’ve all had bad haircuts, it grows back.

Chris: Exactly [laughs] .

Mark: Yeah.

Chris: Many times we, as citizens and as patients, we don’t understand these underlying issues. Many of Emily’s specialists at her facility were not aware.

Some of them had been there for 20 or 30 years as practicing physicians, probably writing scripts for, I imagine thousands of IV meds for their patients. They had no idea that pharmacy technicians compound virtually all IV meds.

I’m proud to say I was able to help get Emily’s Law passed in January of 2009 for the state of Ohio. I’ve continued on, on a national basis, because it varies on a state-by-state basis.

I have carried on this work with the Emily Jerry Foundation’s Pharmacy Technician Initiative and Scorecard as well.

I know I’m skipping around here a little bit, Mark, but going back to what had happened with Eric Cropp, my former wife and I had been separated, and all of a sudden I started getting calls from the news media requesting interviews with me. I said “What’s this about?”

They immediately said, “Well, weren’t you aware that your former wife is pursuing a criminal conviction against the pharmacist that was involved in your daughter’s death?”

I said, “No, I wasn’t aware of this.”

At that point in my life, Mark, even though I had skipped over that angry phase of the grieving process, part of my grieving process which it varies for every individual.

I used to be more embarrassed about it than I am now, but definitely for a few years, I was going through what I refer to as my Lindsay Lohan/Big Lebowski days, living life a little too wild and not really caring too much, but I was establishing this foundation.

As I’m working through all these things, my response to the news media requesting the interviews was to decline them.

Mark: Yeah.

Chris: That’s something that I’ve apologized actually to Eric for. I think it’s important for our listeners to hear this because we all think about things. How would I’ve done things differently during that time?

I would’ve done a lot of things differently, but one of the key ones that I regret and was very apologetic to Eric for was that I would’ve been there by his side during the court proceedings helping to defend him.

I watched it unfold instead in the news media, and I see this guy being vilified for what had happened in my daughter’s death. My solution was to just bow out of the media spotlight, decline the interviews.

As I learn more and I’m following his case, he was convicted of involuntary manslaughter, but the initial charges were he was being brought up on reckless homicide, all these horrible things.

He did receive a criminal conviction and was sent to jail for what had happened with Emily. He was sentenced to six months in county jail, and then six months of house arrest.

He had his license to practice pharmacy permanently revoked.

Right before he was released from jail, I had told my colleagues and the people that I work with in the patient safety communities, started telling them when I was speaking with them one-on-one, Mark. That I would really like the opportunity to be able to come out and publicly forgive Eric for what happened to my daughter to set the record straight.

We, as a society, when these horrible things happen and we determine they are not due to the reckless practice of medicine that we learn from them and we modify the systems.

Because I don’t believe if you have any deep-seated anger, resentment, and animosity I think those are things that are negative to the human condition. I think it causes us to deteriorate from the inside out. It’s partially for my healing process as well.

Eric and I were given that opportunity in May of 2011 for a Discovery Channel patient safety segment called “Surfing the Healthcare Tsunami.” You can watch that on the Emily Jerry Foundation’s website, that clip.

Mark: I’ll make sure we link to that on the page.

Chris: That was a very pivotal moment. Eric and I were brought together for the very first time since Emily’s death.

We were able to look one another in the eye. I felt like I’d done my job because I was able to set that record straight, Mark, and get people, get society, when these tragic events occur and root cause analysis determines it is not due to a result of reckless practice of medicine.

We can all learn from them and modify those systems instead of just going out and lynching an individual for them and letting the systems go.

Because then, when that happens, when people like Eric go to jail and nobody speaks out then I think that it’s natural again, part of human nature, for maybe the upper-level C-suits people, our nation’s medical facilities, and the people that are responsible as administrators for signing checks for vital pieces of patient safety, technology, and equipment that needs to be implemented.

They probably think to themselves Mark when they get a purchase request for a half a million dollars, let’s say, for an automatic IV compounder that’s going to make their facility safer.

I think that these administrators might think to themselves, “Well, Jeez. Times are kind of hard right now economically, maybe we can put off this $500,000 expenditure until next year or until next season.”

Because, in the back of their minds, they think to themselves, “Well, we have the culprit that’s responsible for this horrible tragedy that occurred, and they are rotting in jail anyway so why do we need to spend the extra money?”

Mark: It’s easier to say, “Here’s what the cost of that technology would be, then it is the cost of not having it.” Well, the risk is someone will make a mistake, “Well, we have careful people. We’ll tell them to not make mistakes,” but that’s ignoring human factors and human fallibility.

Chris: Yes. Mark, to speak to what you’re saying right now, the fact that we’re all fallible; we’re all capable of making a mistake. Let’s just take a hypothetical here, Mark. Let’s just take a hypothetical here, Mark. Even if you were a rock star cardiac surgeon.

You graduate top of your class from Harvard Medical School. You’ve been practicing for 10, 15 years without any significant error that you’re aware of reaching the patient. You’ve been responsible for saving countless lives through stellar procedures.

The fact of the matter is God made us all fallible. We’re all capable of making a very human error. Having an oversight. There’s only so much any human mind can endure.

Statistically, chances are pretty good that you being his hypothetical rock star cardiac surgeon, chances are you’re still, no matter how many lives you save, chances are during the course of your career pure statistics and objective analysis is probably going to say that you’re going to have a significant error that reaches and/or proves to be lethal to a patient of yours.

Your work is much like mine in that respect, Mark. I’m trying to get everyone to rally behind those basic core of thoughts.

Mark: Right. Tell us through the Emily Jerry Foundation, you’re doing a lot of work to raise awareness and to rally people behind these issues. You might even say the right way to try to improve patient safety and healthcare quality.

What are some of the main things that you’re communicating and advocating for to help solve this?

Chris: I’m advocating for, I think you hit the nail on the head, Mark, primarily for changes in attitudes and opinions across the nation. Changing the underlying culture of medicine, the negative aspects.

I often tell people, “If I were allowed, for me as a guy and as an individual, to have any job I wanted in the world, because I’ve always loved, ever since I was a little boy, I’ve loved sports cars. It would be to own a sports car manufacturing concern.

“A sports car manufacturing concern that produces state-of-the-art, high technology sports cars that are capable of driving at a very, very high speed, and keeping the occupants safe in that vehicle, while they’re driving at that very high speed.”

Now, if I were the owner of this hypothetical concern, I certainly wouldn’t allow my design engineers, nor do I think you would either, Mark, to allow your design engineers to put cheap tires on that vehicle that would compromise those occupant safety, correct? We probably would not even allow them to put mediocre tires on a car like that, right?

I kind of view modern day medicine on a global basis, and especially here in the United States, in that same way. I believe that we have the high performance sports car built today. We have that today.

Now, what we need to focus on as a society and as the medical community, trying to get around this huge issue of preventable medical errors and loss of life, what we need to focus on is the tires.

I know that’s a little bit of a corny analogy, but I think it’s a good one that kind of drives the points home pretty well.

Mark: It’s not enough to just have a great engine and beautiful design, and a great paint job, and comfortable seats, and all the safety gear inside. All of these elements of the system have to fit together.

I think of the analogies to the auto industry. I mean, gosh! You see what’s in the news, where there was allegations thrown at Toyota. More recent recalls and congressional hearings with General Motors. Design problems with small cars, and ignition switches.

The range, the number of deaths, again not to diminish any one of these accidents of course, 13 to 40 deaths. These are all out in public. There are police reports.

It’s a problem that really a company could move slowly and drag its feet in responding. The government regulators might be slow. Ultimately, these problems occur out in the open. Problems in hospitals, where it’s not 14 to 40. It’s 140,000 to 400,000, depending on which estimate. It’s private. It’s one-at-a-time.

I think that’s one of the things that gets in the way of improvement is this lack of public understanding, this lack of awareness, this lack of pressure.

There certainly aren’t these congressional hearings all the time, hauling healthcare CEO’s in to explain why so many people are being killed by preventable errors. It just doesn’t happen.

Chris: Right. I think the significant points there are increasing public awareness of all of these things. I didn’t discover them until after the fact really. I really wasn’t aware of these things.

Now, that I’m submersed in it though, I even see it to speak to what you’re saying, Mark, on the other side of things, if we’re talking about using analogies from the auto industry especially. I think modern day medicine can be compared to the auto industry in let’s say the early ’70’s, the late ’60’s.

I’ll tell you why. During the early ’70’s, even though I’m an old guy, and I’m going to be dating myself now, Mark, but that’s OK. I’ll never forget. My mother had what I thought as a little boy, I thought it was the coolest mom car out there. She had one of these old Corvair. I don’t know if you’re familiar with that car?

Mark: Yeah. I’ve heard of it. Was this the Ralph Nader car, made famous by?

Chris: This is kind of one of them. I always thought this was a cool car. It’s ironic that you just brought up Ralph’s name, because I’m about to.

Mark: OK, sorry. [laughs]

Chris: No. Don’t apologize at all. This just tells me that you and I are on the same wave length.

I always thought to myself, “Boy! My mom has got the coolest car! I’m so proud.” She’s dropping me off at Little League Baseball, and all the other boys are looking at this cool red Corvair that I’m getting dropped off in.

I always wondered as much as I loved that car, Mark, even as a little boy. I wondered to myself, “Why aren’t there any seatbelts like there are in daddy’s car?” I thought about this the whole time.

Lo and behold! Now that I’ve been submersed in patient safety now, I’m drawing analogies back to those times. We hear about people like Ralph Nader, who in the early ’70’s was a big proponent of safety with respect to automobiles.

How many lives would be saved if the car manufacturers took existing technology that they already had designed in terms of seatbelts, and what have you? In fact, I’ll expound on the “what have you.”

I’ve even heard rumors, Mark, and maybe you can share with me if this is true or not. That there were a few car manufacturers that had actually designed working airbag prototypes that worked in the early to mid ’70’s, at that time.

My point is this technology existed, and had been designed at least for seatbelts. As I understand history, the car manufacturers were reluctant to put the seatbelts in there.

They were fearful that if word got out that just driving a car was an unsafe proposition, that fewer people would purchase their vehicles if they thought that, “Hey. We promote this fact, and we’re going to be showing that our products are dangerous,” and what have you.

Mark: I could probably imagine that was the case. I don’t know the details on the history of development of airbags. I do remember being exposed even in the mid ’90’s. Well, early ’93, doing a summer engineering internship with a major auto maker. We were looking at different types of glass for vehicles.

Generally, automotive glass is engineered to be pretty safe, compared to your average pane of glass, in terms of not having big shards that are going to cut you. It was pretty well engineered as far as glass goes. They were looking at further advances that would have been incrementally safer.

I know there were discussions of, “Well, if we put that product in our luxury cars, the more expensive ones where we can absorb that cost. We’re not putting it in all the vehicles. Oh, my gosh! That opens us up to liability.”

I can imagine there was discussions like that if the technology wasn’t perfect, or if they didn’t put it in everywhere. Even like you said, creating a perception that driving a vehicle at 55 miles an hour has its safety risks, which I think, “My gosh! We all would recognize that.”

I guess, I can appreciate some of that reticence to be forthcoming about trying new things.

Chris: I think analogies can be drawn between the automotive industry and to modern day medicine right now. I think there’s a lot of good analogies that can be drawn from that.

Here, we have the manufacturers in the early to mid ’70’s being nervous or reluctant to truly open up, and I guess for lack of a better word, be truly transparent with the general public about what an inherently dangerous prospect it really was for all of us to drive to the grocery store a couple miles away. It was a pretty dangerous proposition at that time.

Bottom line is we had the solutions. Those being at least the seatbelts. Now, here modern day, flash forward, and we find that in the marketing.

I think I just saw, I think it was a Subaru commercial, where they’re showing the remnants of this car on the back of a flatbed that has just been totally mutilated. You’re wondering to yourself as the viewer, you’re thinking to yourself, “What could have happened to those occupants?”

Here, they’re boasting about their safety features in I believe the Subaru, saying, “Hey! We’re one of the safest vehicles. We’ve put so much money and time into designing these things associated with our airbags, our seatbelts,” all of their automated safety equipment.

Now, they’re conveying that message. They’re being honest and forthright with people. People are now finding that’s a reason they want to buy those Subaru vehicles.

Mark: You look at the National Highway Traffic Safety Board Administration. I’m getting the different acronyms. Mid-afternoon, I need a cup of coffee.

You’ve got these different federal regulatory groups. There’s somewhat standardized and federally regulated safety standards and crash tests and reports that are done, not just by the federal government, but by Consumer Reports and other independent groups.

Healthcare, you’ve got some groups like Leapfrog Group and others that try to do patient safety grades and score cards. There’s really not a similar federal effort that we would have for aviation safety or other types of transportation safety.

I’ve seen articles where Lucian Leape, one of the fathers of the patient safety movement, is advocating for something that would be similar to an FAA for healthcare.

We can point to examples, not just Lean manufacturing, but we can point to other industries, other known best practices that take into account human factors, human nature and dynamics that have led to such dramatic increases in, say, aviation safety. Not to mention auto safety. There’s a lot of things out there.

I think we know what to do, but there’s not the public or political or even management support within a lot of organizations to honestly admit, first off, “Here’s the problem. Here’s the scale of it.”

I think it’s pretty rare. I’ve run across a few hospital CEOs that will talk bluntly to their employees about, “How many patients do we plan on harming this week?”

Obviously, they’re not wanting to, but to talk about, “If we’re not improving processes, statistics would show we are going to harm people this week through medication errors and other types of preventable problems.”

People would say in the Toyota circles, first you’ve got to define the problem, or if you’re trying to say, “We don’t have any problems,” as the saying goes, no problems is a problem.

Chris: Those are words of wisdom, Mark. Without a doubt. Without a doubt, because that’s the whole point that I’m trying to get to, is the fact that if we continue, historically, when tragedies like what happened with my daughter Emily happen…

If that would have happened 20 years ago, it probably would have been brushed under the rug and forgotten, because it’s an embarrassment to the institution where it happens. It’s human nature to try and compartmentalize things that are horribly traumatic and upsetting for us, emotionally, on everybody involved.

Mark: I would have been worried about that occurring eight years ago or even today, like you said. Things being covered up or not being looked at.

Chris: Brushed under the rug. Then, what happens — again, another form of human nature — is the fact that we all try to, when we face a horrific problem or situation that needs a solution, isn’t it human nature? At least for a nanosecond or two, Mark, to try to minimize that problem at hand? Say, “Oh, this isn’t that big of a deal.”

Mark: Or to say, “Well, we’ll blame somebody and punish them and problem solved.” I think that’s where I think part of the discussion with the public needs to not just — and certainly not to be alarmist — but to say, “Look, there are risks of going to the hospital for even the most routine procedure.”

To be aware of those risks, but at the same time, being really careful, like you did at the very beginning of our discussion here, not demonizing the individuals and saying, “Well, don’t go to the hospital because some idiot nurse or stupid doctor’s going to hurt you.” No, that’s not it at all.

Chris: Precisely.

Mark: It’s about being aware of systems. I know you’ve met Laura Townsend from the Louise Batz Patient Safety Foundation. They have an excellent guidebook that I share with anyone I know that is going to be going in for a surgical procedure. I know people have found the guidebook incredibly helpful, because it points out, “Here are the questions you need to ask.”

It does so in a very, I think, matter-of-fact, non-alarmist way. Otherwise, people are going to discover these things on their own.

It’s better to have a little bit of advanced warning of knowing what you need to keep track of and questions you need to ask. In an ideal world, it wouldn’t have to be that way, but if it was you or me or my family, I would certainly be looking out for them.

My wife and I have this deal. We check in on this every once in a while. “If I’m hospitalized, I need you or someone to be there with me, and vice versa.”

Not to be obnoxious to anybody, or not to be disrespectful, but just to be monitoring and overseeing things, even though you’re not a medical expert. Which puts patients and families in a bad position.

I think being aware and having at least some key questions can really help put luck on your side a bit.

Chris: To understand what the core issues are at hand, before going in for treatment, and then subsequently, and this is where I really try and guide people in the general public that are, I guess, not working but concerned about their care or their loved ones’ care. That is, I always try to stress to them the importance of patient and family engagement in your healthcare.

We all need to be involved. You do need to be knowledgeable about things like hospital-acquired infections. I think there are many people that don’t even understand. They’re very fearful of hospital-acquired infections, because we hear about how the news media sensationalizes things, any chance they get.

They’re very fearful of going in for a procedure because they hear about how many people are dying from hospital-acquired infections, but many people are not cognizant of the fact that one of the biggest ways in healthcare that we can reduce hospital-acquired infections, believe it or not, and it’s true.

This is objective fact, and not my opinion. I know you’ll support me on this, Mark, is through CDC hand-washing methods in the medical facilities.

Many people in the public aren’t aware that when they have multiple specialists coming in to see them, during the course of their stay, for any procedure, you have three, four, five different types of physicians coming in to see you and treat you.

You see one of them walk in and not wash their hands. You’re well within your rights as a patient to — very politely and tactfully, though — say to that physician or that nurse, “If you’re going to give me an examination, please wash your hands for me.”

People are afraid to speak up. They’re not going to know to speak up unless they know that that’s where the root of the problem is, I guess.

Mark: Start to wrap up here. There’s so much we could talk about, and I encourage listeners, if you’ve got questions or other things you would want Chris to explore here, I think we had an agreement up-front that we could maybe do another discussion.

Chris: Yes.

Mark: As we start to wrap up, one question I wanted to ask was whether you feel like there’s progress being made. In the time that you’ve been involved in this movement and with the foundation, how much progress do you feel like is being made right now?

Chris: I feel, even though the numbers, the sheer numbers, Mark, which I’ve got that side of my brain which is more analytical about these things. I look at the numbers being so astounding, at over 440,000 lives a year.

To answer that question directly, I do feel that there are some incredible changes happening. I do.

Much of my work is spent, as you know, Mark, going and speaking at different medical facilities around the nation, and spending time with them and their quality teams. Their upper-level C-suite people, their boards of trustees, all of their caregivers. I’m seeing these changes in attitudes and opinions are most prevalent.

I’m seeing those changes occur in the way that they’re viewing these things as they relate to our whole interview we’ve had today. All of those topics we covered today, and I know we covered a lot of them, I am seeing the upper-level. I’m sure you are, too. I don’t mean to put words in your mouth, by any means.

I’m sure you’ll agree that many of the presidents and CEOs that you and I speak with, especially on a one-on-one basis, I think they’re starting to show a change in how they understand and perceive the vital issue of preventable medical errors.

I think when I first started, I think many of them used to think, “Chris, this horrible story of Emily and what happened to her could never…”

They think to themselves, “This could never happen at our facility. We’re top-notch.” Now, today, if I take a snapshot from today, Mark.

I believe that many of them are coming to the realization that what’s changed now is that they realize that, “Hey, chances are that a horrible, awful, unimaginable tragedy like what happened with Emily could and may very likely happen at our facility, so we need to implement the safeguards.

“We need to modify our internal systems and processes and protocols so that these things don’t happen. We need to be proactive about it, rather than just ignoring it.”

Mark: I think there has been some change in thinking. There are some organizations that are, I think, absolutely top-notch, and I give credit to their leaders for really embracing this problem and not just wishing it away. I think it’s not happening as broadly enough as the impatient side of me would want.

Chris: You and I share that, Mark. I’m one of those people that feel like, if I build a logical argument for just about anything, a very objective argument for something, where I’m able to provide facts and things like that — and I know you’re similar in that respect, Mark — then, I feel to myself that I should be able to snap my fingers and that should be able to happen.

What I have learned through doing this difficult work, sometimes, is that the change doesn’t ever happen as quickly as we want. You and I want it to happen overnight, Mark.

Mark: The change and the improvement in the level of safety and quality can happen quite quickly in hospitals. Part of my impatience comes from seeing that it’s been demonstrated, and it might take 20 years or a generation to change an industry. It doesn’t take 20 years to dramatically reduce risk and harm in a particular hospital.

The encouraging side is that if more hospital leaders get to it. We can see great things happening. Whether they’re a small community hospital, or like you said, any large hospital.

I don’t mean to single them out, but if you look at the Josie King story and her death and Sorrel King of course is doing great work to try to help improve patient safety. That occurred at Johns Hopkins.

To their credit, they have also been working with her. Others within Johns Hopkins have done great work to demonstrate and promote patient safety and healthcare quality. That’s about as top-notch, world-renowned as it gets.

Like you said, it’s not lack of training. It’s not lack of people from the right medical schools. It’s not a lack of technology. These are, I think, culture problems, systems problems, management problems. That makes it more fixable.

Chris: Correct. Again, Mark, that’s what keeps me going on a daily basis and getting out of bed early in the morning, going down late at night, and being so passionate about this work.

Is the amount of hope that I have. I’m seeing those changes, much like you are, with organizations like Johns Hopkins taking a leadership position, by looking at things a little bit differently.

By leadership position, I mean addressing the problems at hand. Acknowledging the fact. Stepping up to the plate, much like Johns Hopkins did. The facility where I lost my beautiful daughter, here in Cleveland, Ohio.

They stepped up to the plate, and I believe should be commended for taking a very bold action when they asked me to come and be a keynote during National Patient Safety Awareness Week and then to give three or four very high-profile talks for continuing medical education credits to their people. Inviting me and then promoting it very publicly.

This horrible, horrific, unimaginable incident with my daughter, Emily, occurred at their facility. At least they’re taking that first step, and they’ve taken multiple steps afterwards. Maybe that’s something for another show, Mark.

They’ve taken multiple steps over these past years since Emily passed away to modify their systems and processes.

For them to take that leadership position and actually invite the father of a beautiful little girl that was lost due a tragic, preventable medical error at their facility, I think that was huge.

Much the same way that Johns Hopkins invited our friend Sorrel King, Josie’s mother, into their facility, shortly after it happened.

They’re saying to everybody, “Yes, this horrible thing happened in our facility, but here, public and future patients of ours, look what we’ve done to learn from what had happened. Look what we’ve done to modify things and ensure that patient safety is our number one focus and the best possible outcomes are our number one focus.”

Mark: I’m glad that that’s your focus and that you’re dedicating so much time and energy and rallying others behind this incredibly important mission.

As we wrap here, again, I want to thank you for sharing your story. How people can reach you, the foundation’s website? What do you recommend for people to be able to get in touch?

Chris: Definitely, I would encourage everyone to visit our website, which is www.emilyjerryfoundation.org, and I would also encourage any of our listeners to please feel free to contact me with any of these issues that you might have first and foremost in your mind. My email address is [email protected]

Finally, anyone can feel free to contact me, even directly, at area code 440-289-8662. I would be very, very happy to speak with you and work with you.

If you’re involved with healthcare and what have you, and feel that Emily’s story and the programming of the Emily Jerry Foundation is in line with your efforts, there at your facility.

I’d be very interested in not only working with your facility in the important area of patient safety, but also coming and speaking, possibly, to your caregivers and to your staff, to help inspire them to continue with their efforts.

Mark: I hope listeners who are in the position to be able to consider that, I hope people will do that. Either tell their hospital administrators or professional organizations that they’re a part of to have you come and dialog with them and be a part of the discussion.

There’s so many people out there, working really hard. Their hearts are in the right places. I think we can equip them.

You’re equipping them with what they need to really protect patients. I want to thank you for that, Chris. Thank you for being a guest here on the podcast.

Chris: Thank you very much for having me, Mark. I really appreciate the opportunity and also the continued support you’ve given.

Mark: I’m very happy to. Thanks a lot.


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Mark Graban's passion is creating a better, safer, more cost effective healthcare system for patients and better workplaces for all. Mark is a consultant, author, and speaker in the "Lean healthcare" methodology. He is author of the Shingo Award-winning books Lean Hospitals and Healthcare Kaizen, as well as The Executive Guide to Healthcare Kaizen. His most recent project is an eBook titled Practicing Lean that benefits the Louise H. Batz Patient Safety Foundation, where Mark is a board member. Mark is also the VP of Improvement & Innovation Services for the technology company KaiNexus.

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