Emily Jerry was a two-year-old patient who died during her stay in a hospital due to mismanagement of medical equipment and hospital staff incompetence. She was scheduled to receive chemotherapy but died of detrimental brain damage (Hope, 2020). A series of events that included missing fundamental understanding of solution concentration, disorderly workspaces, lack of focus, and faulty or totally inoperational equipment led to a systemic failure and the death of a child.
It is important to note that during the time of the tragedy, in 2006, the requirements for pharmacy technicians were incredibly different from state to state. Some states did not even have records and registrations of their working technicians, and as such, would not be able to determine who their employees are and what qualifications they have. Other states required ASHP accredited training or passing scores on PTCE exams (Hope, 2020). Many analysts have referred to the differences as unmanageable and even irresponsible. In the case of Emily Jerry, the hospital she was getting treatment from was in Ohio and did not demand their technicians to be registered.
Emily Jerry was expected to receive her final dose of chemotherapy on the 24th of February in 2006. Her prior scans determined that there were no longer any signs of cancer in her body. Shortly after her infusion began, she suffered severe brain damage. This was due to the fact that instead of filling a plastic bag with a standard 0.9% saline concentrated sodium chloride solution, the technician had compounded her own solution with a 23.4% concentrate (Hope, 2020). When the incident was first being analyzed, it was noted that the technician did not discern the primary differences between the two solutions. As such, it was still expected that the pharmacist would have approved of the medication before it left the pharmacy. It was concluded that he did but recorded that due to a disorder of things on his table that needed approval, he had confused the empty saline vials with a different prescription. Additionally, the computerized system in the pharmacy was down and had been as such for an extensive period of time.
This event exposed a substantial issue within the healthcare system that needed fundamental restructuring and reassessment procedures of working staff. Chris Jerry, Emily Jerry’s father, created a foundation in her name to initiate serious and appropriate training for pharmacy technicians in the entire country. Firstly, the foundation indicated the variation in pharmacy technician and pharmacist training qualifications in the United States, which were the core of the problem. Secondly, it graded in each state of a scale of the amount of adequate training offered or the reliability of the tests by which the hired pharmacy technicians were checked. Unfortunately, the case of Emily Jerry is not isolated, as recent studies have revealed that over 250,000 people lose their lives due to medical errors in the United States (Daniel, 2016). Some researchers claim the numbers are much higher due to the fact that physicians, coroners, funeral directors, and medical examiners do not determine ‘human error’ as a cause of death of certification.
With medical mistakes accounting for the third most common cause of death within the United States, the severity of untrained or unregistered staff becomes very troubling. Organizations like the Emily Jerry Foundation continue to promote appropriate training, and even more importantly, serious testing and examination for pharmacists and pharmacy technicians. With collaborative efforts to make new policies, improve the workspaces of medical staff, and provide additional workforces of adequate training, it is possible to decrease the adverse effects of medical errors and mismanagement in hospitals.
References
Hope, K. (2020). A mountain of mistakes: Moving from unspoken tragedy to effective collaboration. CE-PRN, 42(1), 1-40.
Daniel, M. (2016). Study suggests medical errors now third leading cause of death in the U.S. John Hopkins Medicine.