21D Pediatric Adverse Drug Events

The potential for adverse medication or drug-related errors is three times higher in the pediatric and neonatal populations than in the adult population (The Joint Commission, 2008).

Our APSS outline actionable steps healthcare organizations should take to successfully implement and sustain behavior change for high reliability, shared understanding, thorough communication, and meaningful person-centered care across the organization.

Actionable steps include:

Executive Summary Checklist
Leadership checklist guide to determine whether current evidence-based guidelines are being followed in your organization
Performance improvement plan to follow if improvements are necessary
Clinical workflow for preoccupation with workflow for areas of improvement
How to educate patients and family members about the significance of their role throughout the continuum
Guidance on how to measure outcomes

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APSS are revised annually and available free of charge on our website for download.

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Josh Barron

Patient Stories

Josh Barron

As told by Josh’s father, Ridley Barron

It only took a matter of moments for my world to fall part apart that Spring day. We were just a few minutes from our house as we returned from a family vacation when a driver raced through a stop sign and crashed into our vehicle. My wife of twelve years was killed instantly. EMTs informed me that day that I had watched as Sarah took her very last breath. At the same time, my seventeen-month-old son, Josh, had his seat belt snap and was ejected from our minivan as it tumbled down the highway after impact. Volunteers who arrived on the scene found Josh strapped in his car seat about 50 feet away from where our van had come to a stop.

Josh was taken to our local hospital in Southwest Georgia and moved from there, via a helicopter, to a larger hospital in Savannah, Georgia. For the next four days, our family would watch and pray for his continued recovery as we looked to move beyond the loss of his mother, Sarah. On day four his doctor informed me that Josh had a severe head injury but had continued to show steady improvement throughout his time in their care. He even hoped that Josh would improve enough to be a part of the upcoming trip to Middle Tennessee for the burial of his mother. His nine-year-old brother, Harrison, and his six-year-old sister, Abby, would pray each night that their little brother was safe and that he would soon be well enough to rejoin us.

So, it was with great shock that I received that phone call on the morning of day five. Doctors were asking that my family drop everything and get to the hospital as quickly as we possibly could. For us, that would be a 2-1/2-hour trip that would seem like forever. Upon arrival, we were greeted by doctors and administrators who asked us to meet with them in a conference room before they would allow us to go back to Josh’s room. It was in that conference room that the crumbling of my neat little world would reach its pinnacle. I was informed that a pharmacist’s error had resulted in a medication mistake. My son had received five times the amount of phenytoin needed for head seizures that he was having. Five times! I was lead into the room where I watched him die that day. I looked on as doctors made one last attempt to keep him alive but to no avail.

I decided two things that day. My son’s death would not be in vain; God would enable me to do something to bring good from the loss of my two family members. And I would do whatever I could with my story to help keep others from experiencing the needless pain I experienced that day. Mistakes happen. I get that. Health care workers are human. But mistakes don’t have to touch our loved ones. We must do everything we can to make sure that every preventable error becomes a distant memory. Every life matters; every half-second counts!

Candace Downing

Patient Stories

Candace Downing

As told by Candace’s mother, Mathy Downing

Candace’s story is a horrific reminder of the damage medical error can cause.

At eleven years of age, Candace was prescribed an antidepressant, not for depression, but for test anxiety at school. After several months with no noticeable change, the dose was doubled. Candace eventually had a negative reaction to the medication, after being told that she could take an extra pill at night if she was nervous about school the following day.

The adverse reaction sent her to the hospital for monitoring, where instead, she was immediately administered not one, but two sedatives, which never should be given in combination with an antidepressant. Not only that, but the medication was doubled, given intravenously at twice the dosage one would give a 67-pound child.

The result was that Candace began having severe hallucinations, her heart rate doubled, her blood pressure skyrocketed, and she began running a fever. Then two days after being admitted to the PICU, she was given four times the amount of the antidepressant that sent her to the hospital in the first place, while I was informed that the blue pills she was given were Tylenol. Not only did I recognize the pills as antidepressants, our itemized bill validated what I witnessed. She was released two days later, still not eating or sleeping, with flu-like symptoms, and ebbing and flowing hallucinations.

Three days later, while in a drug-induced psychotic state, Candace hanged herself in her room, with no awareness of her actions. While I am glad she did not “suffer,” nothing can take away our needless emotional pain and suffering. Nothing can bring her back.

Emily Jerry

Patient Stories

Emily Jerry

As told by Christopher S. Jerry

Emily Jerry was diagnosed with a yolk sac tumor about the size of a grapefruit when she was about 18 months old. Her doctors and nurses assured me that Emily’s cancer was not only treatable, but curable.

Emily endured months of surgeries, grueling testing, and rigorous chemotherapy sessions. Emily’s treatment had been so successful that her last MRI showed there wasn’t even any residual scar tissue. Emily’s doctors said it was as if she never had cancer.

Regardless, she was scheduled to begin her last chemotherapy session on her second birthday, Feb. 24, 2006. This was just to be sure that there were no traces of cancer left.

Sunday, Feb. 26, after the third day of her last chemotherapy treatment, Emily awoke from her nap groggy. She kept trying to sit up and asked her mom to hold her in her lap. She kept grabbing her head and moaning that it hurt. Emily spotted her mother’s can of Coke that she had on the tray and begged to have a sip. She sipped the rest of the can through the straw in a matter of seconds. She cried some more before she started screaming, “Mommy, my head, my head hurts! MY HEAD HURTS!”

I was just walking in as nurses were grabbing her from her mom’s arms. Emily went completely limp and the nurses began to resuscitate her. Within the hour, my precious daughter was on life support.

Emily wound up brain dead and on life support – essentially dead due to the massive brain damage she had incurred. Our Emily was killed by an overdose of sodium chloride in her chemotherapy IV bag.

We had planned a belated birthday and a cancer-free party for her. Instead, Emily was delivered to the Cuyahoga County Morgue.

My family has been completely destroyed by the preventable and tragic death.

A pharmacy technician who had been working for the hospital for a number of years decided not to use a standard prepared bag of sodium chloride solution (with less than 1% of sodium chloride solution).

Instead, the pharmacy technician filled a plastic bag with a concentrated sodium chloride solution of 23.4%, which she had compounded herself.

When the pharmacy board investigators and others investigating Emily’s death asked the technician why she had made this outrageous error, she replied that she did not know. The pharmacy technician was asked if she knew that an overdose of sodium chloride could result in death. She claimed that she was not aware of that fact. How can a person who works in a pharmacy and compounds medications daily not know that?

At the time of Emily’s death, Ohio didn’t even register pharmacy technicians. In fact, there weren’t even any training or licensing requirements.

As Told By

Christopher S. Jerry

President & CEO, Emily Jerry Foundation Christopher Jerry lost his beautiful two-year-old daughter, Emily, after a fatal medication error in March […] Read More

Actionable Patient Safety Solutions (APSS)

<img src="https://psmf.org/wp-content/uploads/2020/12/Pediatric-Adverse-Drug-Events.svg" alt="" /> 21D Pediatric Adverse Drug Events

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Josh Barron

Candace Downing

Emily Jerry

21D Pediatric Adverse Drug Events