Noise Part 2
Death Is Worse Than a Six Month Sentence
Legal proceedings about Emily Jerry
triggered noise & public awareness
A February 26, 2006, Cleveland, Ohio, pharmacist's error in mixing medication for two year old Emily Jerry took her life. Criminal prosecution of the pharmacist has generated detailed newspaper reports. 1 2 3 4 5 6
For too long, most errors have been ignored by the medical profession and the media. The deaths of children unrelated to celebrities are usually not considered "newsworthy." I have not been able to find any news stories about Emily Jerry's death published in 2006, the year she died. The earliest article I have found is a January 2007 article about "Emily's Law" being enacted. The error was subsequently discussed in newspaper articles covering some aspect of the legal proceedings: the criminal charges against the pharmacist, the licensure hearings against the pharmacist, the pharmacist's being released from jail, or the push for state regulation of pharmacy technicians. Without those events,
I would never have been aware of this case. I fear that the public discussion of this case would not have occurred. Sadly, the only vehicle most families have to advance public discussion of medical mishaps are legal proceedings.
Stories about particular medical errors rarely appear in the press. Notable exceptions include incidents involving Congressman John Murtha and Dennis Quaid's children. Rep. Murtha developed a complication following a routine surgery. The news reports on the surgical complication leading to his death have covered it in detail. 7 8 9 Dennis Quaid has devoted enormous energy to exposing a massive overdose of heparin given to his twins. While such stories about medical errors affecting families of celebrities are rare, the media coverage has directed scrutiny to the underlying problems. Hospital drug errors far from uncommon. Actor Tells 60 Minutes' Steve Kroft Medical Errors Kill Thousands These public discussions are quite valuable.
Patient safety leaders Dr. Robert Wachter (Link: X) and Dr. Michael Cohen (Link: Y) criticize the criminal prosecution of Emily Jerry's pharmacist for a human mistake. They reason that nothing is accomplished by prosecuting an individual for a simple human error. They argue that the criminal proceedings fail to address the underlying "systems issues" that created the error. They conclude that the criminal proceedings fail to solve the problems and may be counterproductive by discouraging reporting of errors.
To evaluate their positions, let us make make a few distinctions. First, let us distinguish two goals: a. being fair to the pharmacist and b. making patient care safer. Just for the sake of argument, let's assume that Wachter and Cohen are correct that this prosecution failed to achieve the first goal, that it was unfair to the pharmacist. While being fair to pharmacists matters, so does the loss of Emily Jerry's life and that of other children. Preventing avoidable patient deaths will prevent criminal prosecutions for manslaughter and negligent homicide. Safe patient care would completely prevent criminal prosecutions for negligent homicide or manslaughter.
Imagine that the pharmacist had been sentenced to a longer prison term, for instance a ten or twenty year sentence, or life in prison. There would have been an outcry had the pharmacist been sentenced to death. Pharmacists, health care providers of every kind, and activists would organize fundraising activities to hire the best appellate lawyers, letter writing campaigns, teach-ins at universities, and perhaps even lobbying for a pardon from a governor or the president. Amnesty International might designate the pharmacist as one of individuals whose case it champions. The effort would be enormous. I would likely contribute time and money to prevent the execution of someone guilty of making garden variety human mistake. Such mistakes do not justify the death penalty.
If the death penalty cannot be justified for so-called ordinary mistakes, then it cannot be justified for simply being an innocent child. Emily Jerry's life was at least as important as the pharmacist's. Preventing the death of the next Emily Jerry is worth at least that much effort: organizing fundraising activities, hiring staff, letter writing campaigns, teach-ins at universities, lobbying the governor or president. We can try persuading Amnesty International and other organizations to give priority to preventing the deaths of the next, the next ten, the next hundred, the next million patients like Emily Jerry.
Emily Jerry's life is at least as important as the pharmacist's life
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.
Most cannot even imagine the anguish. If someone kidnapped or jailed our child for the six months the pharmacist spent in jail, we would be enraged. Suppose our child had been kept for five or ten or twenty years. We read the news stories about a young woman recently reunited with her family after being abducted decades ago. The trauma to Emily Jerry's family is greater. The trauma to families whose loved ones die from medical errors is just as great. Where is the outrage and the demand for change?
Suppose we offered this deal to Kelly Jerry: in exchange for her daughter's life, she spends six months in jail. At the end of the six months, she is re-united with her daughter. If the family had the opportunity to prevent their daughter's death by subjecting themselves to the same penalty endured by the pharmacist, they would be overjoyed.
Those who focus on the plight of the pharmacist completely miss the point. We need to re design medicine so that this NEVER happens again. Small incremental changes are not enough. There have been millions of these errors even though one is too many. Some safety activists wonder why we don't get the point. If the number of patients that are killed by medical errors were killed by plane crashes, the outcry would be overwhelming.
I do not suggest more punishment for this or any other pharmacist. We can eliminate the criminal prosecutions of pharmacists by preventing the dispensing errors that kill people. Preventing these errors is a moral imperative. We just do not get it. 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.
Everyone in patient safety knows that 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.
I found no articles in the press about Emily Jerry's death in March and April 2006. (If I missed one, please let me know. )
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.
Is using the legal system the only way to end the silence?
How do you think we can end these senseless deaths?
What will you do?
