The Pharmacy Error That Took a Tragic Turn

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Pharmacy point of sale software and pharmacy training and licensing can mean the difference between life and death — and for one little girl, it did. Emily Jerry, age 2, died from an overdose of sodium chloride in a chemotherapy bag. “My beautiful Emily’s death was senseless and preventable,” her father, Chris Jerry, writes on the foundation website he created in her honor. What’s Emily’s story, and what can pharmacies do to avoid future tragedies?

The Story of Emily Jerry’s Tragic Death

Doctors diagnosed Emily with cancer when she was just one and half years old. “The tumor was the size of a grapefruit inside her tiny little abdomen,” Jerry writes. Even so, just before her second birthday doctors gave the Jerry family unexpected news. Emily’s tumor had all but disappeared. Hospital staff described her recovery (after several rounds of chemotherapy) as miraculous and ordered one last round of treatment to make certain all of the cancer was out of her system. That final round of chemotherapy cost Emily her life.

Experts attribute Emily’s death to two probable causes. First, the hospital’s electronic system crashed the night before — possibly affecting pharmacy calculations and inventory. Second, an inexperienced pharmacy technician prepared her own chemotherapy bag for Emily’s final treatment. A prepared bag would have contained less than 1% sodium chloride. The custom bag contained up to 23.4% — a fatal dose for Emily.

Chris Jerry’s Ongoing Campaign for Change

Emily’s father, Chris Jerry, continues to tour the U.S., teaming up with hospital and retail pharmacy software companies and campaigning for change. First and foremost, Jerry is pushing for up-to-date pharmacy POS software. Hospital and retail pharmacy software, such as POS software, helps track inventory and confirm or disprove counts by hand. Improved software also “provides real-time visibility into pharmacy inventory, so essential drugs and solutions can be monitored continuously,” according to Healthcare IT News. Jerry is also asking states — particularly those with lax standards about pharmacy tech registration and licensing — to reevaluate pharmacy training programs.

Emily Jerry’s death makes it perfectly clear: the latest pharmacy software and improved training for all pharmacy staff is vital. Jerry continues to ask hospital, outpatient, and retail pharmacies alike to install and/or update systems to the latest software — and save lives in the process.

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