Tragic Pharmacy Technician Error Sparks Pursuit of Strengthened Regulations

With pharmacy technicians taking on increasingly important roles and responsibilities, there is greater potential for their errors to prove dangerous or even fatal.

Such possibility became reality for the parents of Emily Jerry, a 2-year-old girl who died in 2006 due to a preventable technician error.

Emily’s father, Christopher Jerry, revealed that his daughter was diagnosed with a yolk sac tumor when she was approximately 18 months old. Although her doctors had succeeded at nearly eradicating her cancer, Emily passed away during her last scheduled chemotherapy session after receiving a dose of an improperly diluted intravenous (IV) bag prepared by a hospital pharmacy technician.

On the day the fatal error took place, the hospital pharmacy was short-staffed, the pharmacy computer was not properly working, and there was a backlog of physician orders, according to Jerry.

“No technician wants to do anything to compromise patient safety and health, as it goes against their training, compassion, and empathy,” Jerry, the founder and CEO of the Emily Jerry Foundation, told Pharmacy Times in an exclusive interview. “But when pharmacies get overwhelmed, it can be easy to lose sight of that, so it’s important for pharmacies to implement ways to minimize potentially dangerous mistakes.”

After learning about the events that led to his daughter’s death, Jerry resolved not to place the blame on the technician who had made the error, but instead spearhead changes to the pharmacy workflow system that allowed the mistake to occur.

“When these errors occur, I believe that we owe it to all those who are affected to honor them by learning every intricate detail about how these systems break down and these errors occur,” Jerry said. “No one person is responsible for any of these errors. My daughter’s error was due to multiple systems flaws that set those clinicians up to fail, and we need to go back and modify their system so that these errors do not occur again.”

In examining the role technicians play within these health-systems, Jerry was surprised to learn that technicians in his home state of Ohio were not only responsible for tasks such as preparing IV bags, but were also only required to obtain a GED in order to do so.

“I was horrified to find out that anyone with a high school degree could get a job at a pharmacy and start preparing medication, with no oversight by the Ohio Board of Pharmacy,” he explained to Pharmacy Times. “I know that many technicians are equally disturbed by this lack of regulation, as it undermines and devalues their skills and expertise.”

Efforts from Jerry and his allies led to the 2009 signing of Ohio Senate Bill 203, or “Emily’s Law,” which requires all Ohio technicians to pass an examination approved by the state pharmacy board. In conjunction with the American Society of Health-System Pharmacists, the Emily Jerry Foundation also launched its National Pharmacy Technician Initiative and Scorecard, which grades each state on the strength of its technician requirements and regulations.

According to the foundation’s website, New York, Pennsylvania, Michigan, Wisconsin, and Hawaii each have a score of “0,” indicating that they currently have no laws in place regulating pharmacy technician standards. The Pennsylvania House of Representatives recently passed House Bill 854, however, which would require all technicians to complete a training program approved by the state pharmacy board. The bill awaits a vote in the state Senate.

“We established closed partnerships with state boards to help them improve their grades, and the responses have been overwhelmingly positive,” Jerry said. “Ultimately, our goal is to get a more comprehensive version of Emily’s Law in every state.”

Although Jerry remains heartbroken by the death of his daughter, he hopes that her story will inspire pharmacists and technicians to advocate for higher regulatory standards.

“Looking back now, as Emily’s father, I believe in hindsight that my little Emily’s short life here on Earth was truly meant to save tens of thousands of lives going forward,” he told Pharmacy Times. “I want to get technicians around the nation to continue to rally, and to let them know that I want to be their voice. If we all unite together on a national level, we will have a much more powerful voice to elevate the profession.”