RxDoc.Org

Agreed. This is an egregious ruling and is exacerbated by this article in the board newsletter! From ISMP's website:

"The Institute for Safe Medication Practices is the nation’s only 501c (3) nonprofit organization devoted entirely to medication error prevention and safe medication use. ISMP represents over 30 years of experience in helping healthcare practitioners keep patients safe, and continues to lead efforts to improve the medication use process. The organization is known and respected worldwide as the premier resource for impartial, timely, and accurate medication safety information." (source: http://www.ismp.org/about/default.asp)

The Ohio Board of Pharmacy is calling the profession's leading medication safety organization "ignorant" when it comes to a medication safety issue? Maybe it is time the Governor reviewed his Board appointments (http://www.governor.ohio.gov/).

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AAAAAAAAAAAAAHHHHHH. That is a scream! Note the column written by ISMP earlier in the newsletter. Is that the ultimate oxymoron? The fantasy is the Board's. What I have read and learned in conferences is ISMP approached them for conversation before the visit to Eric in jail; talked to hospital reps; reviewed board and court proceedings; talked with Eric's attorney A mistake is just that, a mistake, it is not criminal. So take it to civil proceedings. Make those involved in mistakes do a lot of extra work to learn and teach about the mistake, human factors, SPEAKING UP ABOUT CONDITIONS, just culture. Jail and license revocation does not impress on anyone to practice safely.

Unlike this pharmacist, Emily Jerry did not get out of jail after six months. Emily Jerry will not get out of jail in five, ten or even twenty years. Emily Jerry will not even have the chance to spend the rest of her life in jail. Emily Jerry, well, Emily Jerry got a death penalty. It was an accident, but she is just as dead. How would we feel if the pharmacist received the death penalty?

Of course he would not deserve it. Neither did Emily Jerry.

We need to re design medicine so that this NEVER happens again.There have been millions of these errors even though one is too many.

I am trying to obtain the transcripts of the hearings in court and before the licensure board. After learning of this case watching a CNN piece on it, I contacted Emily Jerry who advised me that the press accounts contain misinformation.

If the energy that is being directed towards denouncing this criminal prosecution could be employed towards solving this kind of mistake, we could stamp them out. Eliminate the dispensing errors..

We can eliminate the criminal prosecutions of pharmacists by preventing the errors like this that kill people. Preventing these errors is a moral imperative. A beautiful little girl dies and our outrage is directed towards the prosecution of a pharmacist who spends six months in jail. Anyone would choose the pharmacist's fate over Emily Jerry's.

Emily Jerry will not be the last two year old child to die of a medication error. There will be at least another ten, another hundred, and another thousand dead children. Are we willing to stop it?

Medication errors such as this one occur daily in America. People die. Had prior occurrences of this error been publicized, perhaps the problem with medication errors would have been solved. Perhaps publicizing such an error in 1994, or 1997, or even one in 2001 could have prevented Emily's tragic death. Imagine that the medication error of February 26 had been avoided. Emily Jerry would be alive. The pharmacist would not have been prosecuted.

Why wasn't Emily Jerry's death, in and of itself, sufficient to spark outrage over and publicity for the medical error that killed her? Our acceptance of such medical errors that kill beautiful two year old children and the fact that these events are almost never reported in the media has allowed the errors to multiply.

We must end the silence. We must express outrage over the death of this child. The moral imperative is to stop these mistakes. If the legal system is the only way to generate attention for these errors, we must use it. Lives are at stake.

At this point, I do not know enough of the facts to argue that the pharmacist deserved to be prosecuted. I am trying to get more information.

Emily Jerry did not deserve to die. Can we focus a little bit of our energies on preventing it from happening again? If the criminal prosecution causes us to do that, then something very good has come out of the prosecution.

If I am in error, kindly correct my false beliefs.

Lee Tilson
www.rethinkingpatientsafety.com

Lee, you are so correct that this thread has not paid enough attention to Emily Jerry. Thank you for pointing that out. Please view the links for more eduction on this case. Also please re-read the Lucian Leap quote -- that is what we are trying to get across.

How can we work together to prevent injuries like this from happening in the future?

My goal is to prevent what happened to Emily Jerry from happening again. We can disagree about everything else, but still work together to prevent this from happening again. How can we do that?

I took no joy in the jailing of the pharmacist. I doubt that the family did.

The compelling moral issue is how to prevent the injuries to patients. Will you work with me on this?

Lee Tilson
www.rethinkingpatientsafety.com