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An injustice has been done: Jail time given to pharmacist who made an erroR

Posted August 21, 2009

Since Friday’s sentencing of Eric Cropp, an Ohio hospital pharmacist involved in a tragic medication error, staff at the Institute for Safe Medication Practices (ISMP) have been deeply saddened and greatly troubled to learn that he received 6 months in jail, 6 months home confinement with an electronic sensor locked to his ankle after his release, 3 years probation, 400 hours of community service, a fine of $5,000, and payment of court costs. Eric made a human error that could have been made by others in healthcare given the inherent weaknesses in our manual checking systems: he failed to recognize that a pharmacy technician he was supervising had made a chemotherapy solution with far too much sodium chloride in it. The final solution was supposed to contain 0.9% sodium chloride but it was over 20%.

As the president of ISMP, I have not been able to stop thinking about Eric’s situation. I care about the injustice that happened to him because I have spent my entire career spanning more than 30 years trying to help others understand and prevent medication errors. I have never met Eric, but I am familiar with many (certainly not all) of the underlying conditions that contributed to the error. Some details have been provided in the local and national news media; however, I also have reviewed records stemming from Ohio State Board of Pharmacy hearings. I have heard firsthand accounts from others, including a pharmacist who attended a hearing and listened to testimony about the event at the Ohio State Board of Pharmacy, which permanently revoked Eric’s license. I also have been in contact with Eric’s attorneys, Richard Lillie and Gretchen Holderman of Lillie & Holderman, who suggested that I write a letter to the Honorable Judge Brian J. Corrigan in the Cuyahoga County Court of Common Pleas in Cleveland, OH, in support of leniency and avoidance of imprisonment. The letter can be found here. Regrettably, the judge appears to have given my letter little regard, and it likely had little impact on the outcome of the legal proceedings.  

As learned from the sources above, the details of this tragic error are as follows. When Eric Cropp came to work on the day of the event, he learned that the pharmacy computer system was down and his assistant in the preparation area for intravenous (IV) solutions was a pharmacy technician who, according to press reports, was also planning her wedding on the day of the event and, thus, distracted while working (see link to press account below). With the pharmacy computer system down, a backlog of physician orders had developed, creating incredible time pressures for Eric. A nurse had also called requesting the chemotherapy solution (for the young child who died) immediately, which ultimately may not have been warranted. This added more time pressures to Eric’s workload. According to a witness at the state board hearing, the chemotherapy was not needed until much later that afternoon. Testimony at the board hearing also uncovered that Eric was working short-staffed that day had no time for normal work breaks.  
The technician started to prepare the chemotherapy. We do not have complete knowledge of exactly what caused the sodium chloride overdose in this case. However, when preparing IV chemotherapy, some pharmacies remove fluid from a bag when they have to add a large volume of medication to infuse, and then add additional fluid to the bag and titrate with 23.4% sodium chloride injection to bring the final concentration of the infusion to whatever was prescribed (usually not more than 0.9%). Or, they start with an empty bag and follow a similar process. But compounding the solution from scratch is error-prone and such exactness of base solutions is most often unnecessary from a clinical standpoint. According to one press report the solution was more than 20 times more concentrated than it should have been.

Many years ago, ISMP added sodium chloride 23.4% to our high-alert drug list, which is a list of drugs that are extremely dangerous when involved in medication errors. The complete list can be viewed at: www.ismp.org/Tools/highalertmedications.pdf. We have called for special storage, handling, and check systems for these drugs, procedures that may not have been in place in Eric’s hospital. Communication failures between technicians and pharmacists, IV compounder-related failures, inadequate documentation of the exact products and amounts of additives, and other system issues, have contributed to other fatal errors. We have also seen compounding errors and subsequent failed double-checks due to adverse performance-shaping factors such as poor lighting, clutter, noise, and interruptions. As noted above, in this particular case, news reports suggest that Eric felt rushed, causing him to miss any flags that may have signaled an error.

Eric did not make the error himself. Still, he did not notice that the technician made the error when he checked her work. Such an error is crucial, but we have no knowledge regarding how Eric missed the technician’s preparation error other than the fact that he is human and thus prone to human fallibility. I have no doubt that the work pressures and working conditions mentioned above played a significant role. But the price of that error was ever so costly: a little girl named Emily Jerry received an incredibly high amount of sodium chloride. After receiving the chemotherapy later that day, she suffered a terrible headache and thirst, and she soon lapsed into a coma and died.

As expected, the child’s family was devastated, as was Eric, his colleagues at the hospital, and everyone in healthcare who was made aware of the tragic event. A February 2008 USA Today article told the story publicly. The Ohio Board of Pharmacy became involved and Emily’s mother, Kelly Jerry, participated in the board hearing as a witness for the state. She also appeared later in court. As an articulate but anguished parent, Ms. Jerry was compelling in her quest to have Eric’s license revoked, and as of last week, even to have him imprisoned. Her emotional testimony has been truly heart wrenching as she holds up a picture of Emily.

The Jerry family’s efforts convinced state politicians to pass Emily’s law, which requires a minimal level of education and certification of pharmacy technicians. This is an exceedingly important milestone for medication safety which ISMP fully supports. We also can understand parental anger and frustration with the healthcare system and those closest to the error that cost their daughter her life. However, we cannot stand by without speaking out regarding the injustice of throwing healthcare professionals who make mistakes—even deadly mistakes—into the criminal arena when their errors were unintentional, caused by system failures and uncontrollable human factors.

According to minutes of the pharmacy board hearing that resulted in revocation of his license, after the Emily Jerry incident Eric went on to make other medication errors, although it appears these incidents occurred in a retail pharmacy. I have no knowledge regarding the specifics of these errors or how the board became aware of them; whether they were captured before they reached the patient, etc. But who will not agree that being involved in a fatal error in any capacity will surely lead to emotional stress, preoccupation, and distractibility that can lead to additional errors in the immediate aftermath.     

In the past, ISMP has, at no cost, helped to defend healthcare practitioners who have been unjustly targeted for criminal indictment after a medication error, as happened with Eric. At times, our knowledge of the events has been gained from direct on-site investigation, similar to the role the National Transportation Safety Board plays when an airline crash occurs. We have published our findings for a few of these events, including a fatal medication error in an otherwise healthy newborn that led to criminally negligent homicide charges against three Denver nurses. An ISMP article about a fatal medication error during labor and delivery that resulted in the death of a young mother and criminal negligence charges for a Wisconsin nurse will appear in a November or December issue of The Joint Commission Journal on Quality and Patient Safety.

ISMP has also supported patients and family members after tragic medical errors have harmed them or their loved ones. Quite regularly, we hear from patients and family members who have been victims of medication errors, and help them through the healing process by anonymously publishing the events to maximize widespread learning from the error and encourage prevention strategies. On occasion, our work with patients and families has led to a public health advisory issued by the FDA.  

I wasn’t invited but wish I could have been given the opportunity to speak on Eric’s behalf at the board hearing and at Eric’s sentencing. All who work in healthcare can understand how the Jerry family must feel about Eric and the health system that let their little Emily down. I can’t say that I wouldn’t feel the same way if I lost a loved one to a medical error. But I fail to see how the Court’s action on Friday will be effective at anything other than serving a desire to see Eric go to jail as punishment for making an error that led to Emily’s death. It has been my observation that many who have been harmed from medical errors find it possible, even healing, to recognize and forgive human fallibility, especially since human error is not a behavioral choice, and many of the system issues that contributed to the error were beyond Eric’s control.

I expected more from the Ohio State Board of Pharmacy and the Honorable Judge Brian J. Corrigan. I had hoped they would be able to rise above the emotionally charged atmosphere in this case to give Eric Cropp a more just resolution to this event. Based on my knowledge of the error and my experience in analyzing the causes of medication errors and human failures, I believe with certainty that Eric was not treated justly by either the Ohio Board of Pharmacy or by the Honorable Judge Corrigan’s court. What good can come from imprisoning Eric and destroying a man, who, up until the tragic event, had an excellent professional record? 

In fact, I believe the undeserved harsh treatment of Eric will have a potentially disastrous effect in healthcare. Some will ask, “Why disclose errors and risk going to jail?” That, in itself, is a tragic testimony to the impact of this case and one that could cause a horrible backlash against the patient safety movement. In time, if we continue to see the legal system issuing criminal indictments when medical errors occur, we could see how young college students may not be drawn to legally “risky” professions or tasks within professions like pharmacy, such as preparing IV medications using high-alert drugs.

In fact, most healthcare professionals unwittingly put themselves at risk for criminal indictments when they enter the profession. They are fallible human beings destined to make mistakes along the way, as well as to drift away from safe behaviors as perceptions of risk fade when trying to do more in resource strapped professions. Many healthcare professionals already fear making that one error that could result in the harm or death of a patient. Escalating application of criminal error laws also serves as a reminder that a harmful error—often similar in form to minor mistakes we all make on a daily basis—could also strip away a hard-earned and cherished livelihood, the ability to help others, and personal freedoms perhaps once taken for granted, as has happened to Mr. Cropp.

While the law clearly allows for the criminal indictment of healthcare professionals who make harmful errors, despite no intent to cause harm, it will long be debated whether this course of action is fair, required, or even beneficial. The fact remains that the greater good is better served by fixing the medication-use system issues that allow tragedies like this to happen. By focusing instead on the healthcare professionals involved in the error—the easy targets—one can easily avoid addressing inherent system problems.  

The focus on the easy target in this case makes my colleagues and I wonder whether any regulatory or accreditation agency in Ohio, or anywhere else for that matter, has taken any steps to ensure that all hospitals learn from this event and adjust their systems to prevent the same type of error. I am unaware of any Ohio state action to bring the system failures in the Emily Jerry case to the attention of Ohio hospitals. I also do not know of any visits undertaken by state surveyors to detail what the expectations are for implementing prevention strategies, at least those that have probably been put in place at the hospital where Emily died. If nothing has in fact happened, the death of this little girl is a heartbreaking commentary on healthcare’s inability to truly learn from mistakes so they are not destined to be repeated.

Media References

 

Michael R. Cohen, RPh, MS, ScD
President,
Institute for Safe Medication Practices
200 Lakeside Drive, Suite 200
Horsham, PA 19044
web: www.ismp.org
tel: 215 947 7797
fax: 215 914 1492

 

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