The father of a 2-year-old who died in 2006 due to a medication error at Cleveland’s University Hospitals returned to the site of the tragedy to stress to clinical staff the importance of openly reporting medical mistakes.
“Human error is a component of medicine, but if we respond correctly when these tragedies occur, we’ve got so many smart minds in medicine that we can fix this,” said Chris Jerry, CEO of the Emily Jerry Foundation.
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University Hospitals Case Medical Center invited Jerry to speak with staff at the hospital’s Quality and Patient Safety Fair, which coincides with National Patient Safety Awareness Week.
Jerry’s daughter Emily died after a pharmacy technician at UH’s Rainbow Babies & Children’s Hospital incorrectly mixed a saline solution as Emily was finishing up chemotherapy treatment. The Jerry case sparked the passage of Emily’s Law in Ohio, which created licensing and minimum education requirements for pharmacy technicians.
Jerry has spoken out against the criminalization of medical errors by arguing that prosecuting health workers will only make them less likely to report errors and make the same errors more likely to be repeated.
A UH official listed some of the patient-safety initiatives the hospital has undertaken in the wake of the Jerry tragedy. Here are a few:
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- Minimization of compounding medicine: When possible, UH pharmacists use off-the-shelf solutions rather than mixing solutions themselves
- Locking up high-risk, high-concentration substances
- Requiring double-signing of bags that contain medication
- Established a “critical-incident management team” to provide emotional and psychological support for the “second victims” of medical-error cases — hospital employees affected by such tragedies
- Engaged the Institute for Safe Medication Practices for reviews to provide process-improvement suggestions
