Learning from errors to ensure accurate medication delivery
Healthcare system designers who ever feel the need to be reminded on why their work is essential need only spend a few minutes with Chris Jerry.
He was a veteran of the healthcare technology world, with more than 10 years experience as a sales manager of medical devices, when doctors discovered a large yolk sac tumor in his eighteen-month-old daughter, Emily. Jerry’s confidence in medicine was rewarded for a time. A series of surgeries and chemotherapy sessions were successful in removing the tumor and Emily was close to a full recovery.
But on what should have been Emily’s last day of chemotherapy, the hospital’s EHR system went down, starting a chain reaction of preventable errors. By the time Emily’s medication was prepared on that Sunday afternoon, the system had been down for ten hours and pharmacy orders were backed up. The pharmacy technician preparing Emily’s chemotherapy could not find a standard 0.9% solution and used a 23.4% solution instead. Several hours after receiving the dosage, Emily suffered massive brain damage, and by the next day she was dead.
Devastated by the loss, Chris Jerry resisted the temptation to blame the tragedy on the technician. He decided to channel his energy into action.
Jerry founded the EmilyJerry Foundation, and he is now working fulltime to raise awareness of technologies that can reduce human errors. “There’s no way I can bring back my little girl,” he said, but he believes that if he can help speed the adoption of these new systems, other tragedies can be avoided.
Among those solutions is medication tracking throughout a hospital using wireless RFID sensors. A system sold by MEPS Real-Time, Inc., provides real-time visibility into pharmacy inventory, so essential drugs and solutions can be monitored continuously. And to check the composition of a medication, IV sensing systems can provide real-time identification of solutions using sensors; a system introduced by S.E.A. Medical uses impedance spectroscopy to determine the concentration of compounds in a solution almost instantly.
“Technology is able to precisely measure the amount of the medication or prevent the wrong medication from being administered,” he said. “Thereís not a caregiver on the planet that means to do anything that would compromise the care of their patient. When mistakes happen, the caregivers are hurt. So why do these things happen?”
Jerry says that the medication delivery systems in hospitals do not have the quality control standards they could.
“I believe that Emily’s short life was meant to be the catalyst to change. Instead of brushing mistakes them under the rug, we should learn from them and make changes that may save tens of thousands of lives.”
Jerry will be speaking at HIMSS 14 as part of the Intelligent Hospital Symposium, Sunday, February 23, 2014, 8 a.m. - 5 p.m. at the Orlando Hilton.