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A painful experience...
I just did something that may be the bravest thing I ever did, or the stupidest... I relived my experience as the maker of a medication error in an article that will be published in Pharmacy Practice News. It's amazing how clear that memory is, how immediate it is, and how it still affects me emotionally even just to talk about it. That memory is 31 years old. 

I think I got started down this road as a result of spending the morning with Chris Jerry. If that name doesn't ring a bell, he is the father of Emily Jerry, the little girl who died as the result of a tragic medication error in which 23.4% Sodium Chloride rather than 0.9% Sodium Chloride was used to reconstitute what would have been her very last, "just in case" dose of chemotherapy. Chris tells me that the radiological images showing her progress were just incredible; they had only decided to do this dose "to be certain there were no lingering cancer cells".

Chris talked about Eric Cropp, who he has publicly forgiven, and with whom he speaks publicly about the importance of systems thinking in error prevention, as well as about the need for consideration for what Albert Wu has described as "the second victim" of a serious medical error, the healthcare provider who commits the error.

Talking about his experience brought me clearly back to the day that I learned that I had sacrificed care to the god of productivity, and very nearly killed two children. It is a mistake I never made again, but I was seriously impaired for several weeks after that.

While all of us have probably known someone who takes unacceptable risks and needs to be accountable for those decisions, most of us are careful, and none of us comes to work in the morning wondering who we can hurt or kill today.  Yet the reality is that we cannot avoid error. I have been doing research on this for a presentation I am doing over in the UK, and have learned that, given the kind of work we do, the risk of error is at least 3%, more likely as high as 10%. The good news is that most of the errors are benign, and often, someone else catches them. But the odds are, sooner or later one of them won't be.

That's one of the problems with our current model of practice. We put a pharmacist at the end of an assembly line operated by people with highly variable skill and training, and attempt to inspect quality into their product. That model worked when those people were literally our apprentices and were learning the art (not the science) of our practice from us as masters in the 18th century. But the both the amount of knowledge we must apply to the process, and the pace at which it must be performed have risen exponentially since that model was adopted and that model simply cannot keep up with current demands.

Industry realized this a long time ago. You will not find a pharmacist standing at the end of a production line at Eli Lilly inspecting every vial of Insulin as it comes off the line. Industry learned that you cannot inspect quality into a process at the end; you have to build it into the process every step of the way. Interestingly, we all seem to consider products produced by industry to be superior in every way to anything we can prepare in the pharmacy but seem to be completely unwilling to learn from them how they do that.

What really embarrasses me is that Warren McConnel once challenged me with this same thought in 1975 at the ASHP headquarters, and I didn't get it then, either. It only took me 30 years... my apologies Warren, you were so right.

As we look at our Pharmacy Practice Initiative, one of our motivations for change should be the realization that our current system will never produce the level of safety that our society demands. We need to re-architect that practice to have built-in safeguards, many of them automated, that will help detect and prevent errors before they become harm. We have to study and perfect those safeguards to make them continually better.

Chris Jerry has founded and runs the Emily Jerry Foundation, whose tag line is "let the healing begin" to advocate for medication safety and for the care of the second victim in medical error.

I will have the privilege of interviewing Chris during an educational session at the Midyear Clinical Meeting in New Orleans on Monday morning at 07:30. I hope to see you there.

And, as always, I would like to hear what you think about this.
Created By: Dennis Tribble On: Wed, Oct 05, 2011 09:16 AM

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Louis Kynard October 28, 2011 4:11 pm
What resonates with me is this story just brings back home how important it is for those of us who have the ability to move the needle of change have to be forward thinking and not settle for small changes. We are undertaking a major model change at my facility and it is very difficult for the team to understand that change must happen if we are to improve the safety of our patients. I remember the Emily Jerry tragedy because at the time I was a pharmacy director in Ohio and we could see regulatory changes on the horizon. I do applaude the Ohio State Board of Pharmacy for requiring pharmacy technicians to become certified. I am now a pharmacy director in Michigan and recently changed our requirements to only hire certified technicians. Unfortunately right now it is not a requirement in the state of Michigan (but it is under discussion). But the key is we simply have to do whatever we have to do to protect those people who depend upon us to protect them. And as pharmacy leaders we have to make the bold changes required to make it happen. In the case of my facility, Bronson Methodist Hospital, it is "Raising the Bar" as our CEO Frank Sardone would say. In my mind it's all about patient safety and the Pharmacy Practice Model has to support that.
Sammuel Anderegg October 26, 2011 8:13 pm
A very meaningful statement from Mr. Mconnel. I think one key world here is "automated." We need to implement, evaluate, and improve our automated distribution systems, clinical decision support software, bar-code scanning tools, etc. to make it next to impossible for prescription, distribution and administration errors to occur. Improving automation and technology will allow pharmacists to spend more time with patients providing direct patient care, and more time with the health care team to evaluate the APPROPRIATENESS of therapy!
Ashley Overy October 05, 2011 10:30 pm
Ironically, this strikes home three-fold for me. First, I'm from Ohio and was early in pharmacy school when I heard about the Emily Jerry tragedy. Secondly, Chris spoke at Ohio Northern earlier this year. Finally, I'm currently in the first week of my medication safety extern rotation at Riverside Methodist Hospital in Columbus, OH.
It's hard to hear about your struggle with having committed your own error and knowing your intentions, like those of all aspiring pharmacists, were to do no harm. I look forward to the initiatives of the PPMI and hope that we can gain the support of people like Chris Jerry and Dennis Quaid to repair the system.
I look forward to continuing to learn about medication safety and know that the information I gain will be useful in my career.
Thanks for sharing your thoughts.
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