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.
JParadisi (Retired) RN Blog 
I am a pharmacist. I have mixed chemo and worked in an institution where only I or pharmacy students mixed chemo. I did not feel that our technicians had enough knowlege about the dosing of these drugs to perform this task. When checking tech who do mix IV.s The requirement is that all ingredients used would be visable for the pharmacist to view. In a case such as this, when high risk meds ( Chemos)are being dispensed to a high risk population ( children) extra attention neeeds to be on checking. That being said, there was never a day that went by, where I was not thankful that I did not contribute the the patient’s pain and suffering or as in this case death. I cannot defend this pharmacist, I can empathize with his situation. And if I were him, I would gladly sit in jail for the rest of my life. I can think of no appropriate restitution on his part and no punishment that would ever undo this tragic event
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I agree that the catastrophic medication error which caused the pain and suffering of this child and her family is unconscionable, and that there is no restitution that will undo this tragic event. However, the criminalization of unintentional errors is not likely to prevent them from occurring. Ohio’s “Emily’s Law” requiring education and certification of pharmacy technicians in that state, is a step in the right direction. Making health care work environments safer so that patients are not harmed and no one has to sit in jail is a more effective approach to this serious issue. Criminalization of unintentional errors is ineffective, and does not promote patient safety, retention of health care professionals, or encourage people to become health care professionals.
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I am an ex-prosecutor. I can’t imagine my former boss ordering me to prosecute a case like this. I like to think that if ordered to do so, I would advise that I would rather get canned and flip burgers.
At least in Washington State, for involuntary manslaughter you have to prove not just negligence but criminal negligence, which basically means I know it is negligent, there could be huge consequences, but I don’t care. I don’t see it here.
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Exactly, I don’t see criminal intent here either.
As an ex-prosecutor, perhaps you can address a question for me: At the time this event occurred, the only requirements for pharmacy technicians in the state of Ohio, was that they be 18 years of age, and never convicted of a felony. 26 other states in the U.S. require training,testing and certification of pharmacy technicians through their states’ Board of Pharmacy. Does the state of Ohio bear any responsibility because it did not institute certification for pharmacy technicians, and thereby protect patients, prior to this case? The mixing of medications by pharmacy technicians is an accepted and common practice in hospitals. It seems to me that the state of Ohio holds some accountability too.
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I am a pharmacist. This may be a scandal to some but all health care workers make mistakes. Most of the time pharmacists make mistakes they have failed a basic tenet of safety. However, in most cases I guarantee you they were under a great deal of stress. Very often pharmacists are doing five things at one time. In out-patient settings (e.g. drug stores etc.) patients yell at you because you’re not getting their prescription fast enough. In the hospital nurses and doctors get on the phone and ask “where’s my patient’s medication?”. In this case all the orders were backed-up because of computer down time. The mistake this man made was to try to maintain service when he should have slowed the pace and let things fall apart. After this ruling many pharmacists will.
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You raise some excellent points, Mike.
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As a pharmacist, I think it is unacceptable that someone be held criminally liable for a dispensing error. It is a tragedy what happened and I am not disputing the board’s decision to revoking his license or under ackowledging the family’s tragedy. However, what ever happened to “you not only have to commit the crime but have the intent”. Where is the intent? A pharmacist makes a vow to improve the health of patients and its something we honor everytime we practice.
I had to work under very stressful conditions in retail where you work 14 hour days, working without breaks, and trying to do 5 things at once while pasting a smile on your face. It could easily be any pharmacist in Eric’s situation. Nothing is going to bring the child back and I think the best thing to do is learn from this and making work conditions better for pharmacists so that there is less of achance that this tragedy occurring.
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I believe you are right in asking if criminal prosecution for medication errors will improve patient safety. Work conditions and other factors (affecting all members of the health care team) contributing to errors, lethal or not, need to be examined and put into place if patient safety is our goal.
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