The Institute for Safe Medication Practices (http://www.ismp.org/) published an article in their August 27, 2009 newsletter, describing a horrific medication error that ended in the death of a child in an Ohio hospital. Just typing that sentence brings tears to my eyes.
On August 14, 2009, Ohio pharmacist Eric Cropp was sentenced to 6 months in prison, 6 months of home confinement, 3 years of probation, 400 hours of community service, $5,000 fine, and payment of court costs. The Ohio board of pharmacy has permanently revoked his license. He did not mix the chemotherapy. It was mixed by a pharmacy tech, who inadvertently used 23% saline as the base solution for the infusion that killed the child.
Documentation from the case further shows that on the day the medication error occurred:
- The pharmacy computer system was down in the morning, leading to a backlog of physician orders.
- The pharmacy was short-staffed on the day of the event.
- Pharmacy workload did not allow for normal work or meal breaks.
- The pharmacy technician assigned to the IV area was planning her wedding on the day of the event and, thus, highly distracted.
- A nurse called the pharmacy to request the chemotherapy early, so Eric felt rushed to check the solution so it could be dispensed (although in reality, the chemotherapy was not needed for several hours)
The article Ohio Government Plays Whack-a-Mole with Pharmacist defends the right of health care professionals and patients to expect safe and consistent systems and policies from hospitals to prevent the conditions and circumstances creating unsafe work environments, such as the one that has destroyed the life of a child, her family, and pharmacist Eric Cropp. Please read this article.