My guest for Episode #203 (and for Part 2 of our discussion in episode #207) is Chris Jerry, founder of The Emily Jerry Foundation. The foundation was created in the aftermath of the tragic death of his daughter, Emily – a preventable medical error caused by a number of factors and bad systems. You can read Emily's story here.
I first learned about this tragedy a few years back and I blogged about it:
Some people ask, “Why are you defending a pharmacist who screwed up and killed a sweet little girl?” The main victims were, of course, Emily and her family. That doesn't mean that a simplistic response of punishing and jailing one person will do anything to protect other patients in the future… and Chris Jerry agrees with that view.
I saw Chris speak at a conference earlier this year and we finally found an opportunity to record a podcast after talking about this for a few years off and on. The story is powerful and I admire Chris for his work and advocacy to help others — as a way of honoring Emily and her life and memory.
In this first part, Chris tells the story of what happened. Again, also check out Part 2, which was released later.
For a link to this episode, refer people to www.leanblog.org/203.
Interview with Eric Cropp, the pharmacist who was convicted and jailed (something Chris Jerry doesn't think was fair or just):
Chris and Eric meeting and speaking:
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.
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?
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?
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 https://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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