The following post was written by Chris Jerry of the Emily Jerry Foundation. Chris tragically lost his daughter as a result of a preventable medical error made by a pharmacy technician. We are grateful to Chris for his courage in sharing his story as well as for the work he is doing to bring light to this important issue.
Before the loss of my beautiful daughter, Emily, to a tragic preventable medication error in 2006, like most people, I had no knowledge of the vital role that all pharmacy technicians play with respect to safe pharmacy practice.
Shortly after Emily’s death, I decided to establish the Emily Jerry Foundation (EJF), in an effort to create awareness about preventable medical errors as well as to be an active part of the overall solution in preventing them.
I reached out to my friend Michael Cohen, from the Institute for Safe Medication Practices (ISMP), to help explain the overall function and responsibilities of a pharmacy technician. Michael imparted some words of wisdom by sharing an analogy that really hit home with me, one that I will never forget.
He said, “Chris, always think of pharmacy technicians as being the “team” and the supervising pharmacists as being the “coaches” in any pharmacy setting.” He went on to say, “What coaches wouldn’t want to have the best trained and most qualified team to ensure a successful and victorious season?”
He then explained, that a truly “victorious season” in any pharmacy setting, can be equated to having no medication errors that actually reach a patient receiving care. That simple analogy made sense to me back then and still resonates with me today.
Due to the fact that pharmacy is really the only modality in healthcare that truly works in the background, especially in hospital pharmacy, like most people, I was naturally clueless as to the overall scope of practice that pharmacy technicians have in modern day pharmacy.
For example, I had no idea that in virtually every one of our nation’s hospitals, pharmacy technicians have the important responsibility of compounding nearly ALL IV (intravenous) medications, which go directly into patient’s circulatory systems.
In addition, most states have little or no requirements in regards to pharmacy technician training or certification. On the EJF website, we have created an interactive National Pharmacy Technician Initiative and Scorecard, so you can see exactly how your state ranks.
I was absolutely horrified to learn that my little girl had died from a sterile IV compounding error, made on the part of a pharmacy technician, who did not have the proper training or core competency to know the difference between a standard bag of saline with 0.9% sodium chloride, versus hypertonic saline, which has a concentration of 23.4% sodium chloride.
Technically, my daughter tragically died as a result of being overdosed on hypertonic saline.
However, as Emily’s dad, I feel as though what actually caused her death was a lack of understanding regarding the true importance and vital role that pharmacy technicians play on the clinical “team”, helping to ensure the best and safest possible outcome for each and every patient receiving healthcare.
This is precisely the reason why I feel so strongly that pharmacy technician training is a matter of life and death for all of us! As every single one of us will receive healthcare at some time over the course of our lifetimes.
Above all else, well trained, competent, and reliable pharmacy technicians can drastically reduce any facility’s overall medication error rate. We must fully support technician training and certification, and never ever forget the vital role that technicians play; there are countless lives at stake!