Pharmacists have an opportunity to find out what the penalties are in Ohio for making a mistake during a medication study. An Ohio based company is administering the study, and they’re looking for volunteers. Pharmacists must sign a contract to take part. The terms require participating pharmacists to appear in Ohio courts for legal actions related to the contract, where any dispute shall be governed by the laws of that state. Some pharmacists have declined taking part in a study binding them professionally to a state that criminalized medication errors. As predicted, the felony conviction of Eric Cropp has implications beyond state borders.
On Tuesday, February 16, 2010, JParadisi RN’s Blog had the most site hits since its debut in January, 2009. The day is notable, because the blog’s post Whistle Blowers & Patient Advocates: When the Nurse Stands Alone was mentioned by Shawn Kennedy on the AJN blog, Off the Charts. I assumed the two events were connected. Imagine my surprise: they are not. The stats for JParadisi RN’s Blog show that the most popular post on February 16 was an older post: Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp or His Patient. For the entire week that post and the posts with updates about Eric Cropp were the most viewed on my blog.
Eric Cropp served 6 months of imprisonment for involuntary manslaughter in the death of 2 year-old Emily Jerry. Emily Jerry died when she received a chemotherapy solution containing a lethal dose of sodium chloride mixed by a pharmacy technician at the hospital where Eric was the supervising pharmacist. The Ohio Board of Pharmacy stripped Eric of his license prior to his conviction. Now a convicted felon, he will never practice pharmacy again.
Why the renewed interest in the Eric Cropp case, during the immediate aftermath of the Anne Mitchell trial? Anne Mitchell, RN was publicly supported by the Texas Nurses Association and the American Nurses Association. The TNA donated funds for Mitchell’s legal defense, and the Texas Medical Board acknowledged Mitchell’s duty as a patient safety advocate. Mitchell was found not guilty. There were no fatalities in the Anne Mitchell case. The most obvious difference drawn from a comparison of the two trials is that a child’s death initiated the criminal charges against Eric Cropp. Perhaps this explains why pharmacist professional associations appear silent on the matter. Searching two prominent organizations websites with the keywords “Eric Cropp” I found only one article about the case on one site, and none on the other. Granted, defending a person accountable for the accidental death of a toddler creates an unpopular challenge in public relations.
Physicians are familiar with lawsuits involving the death of patients. It is rare for a doctor to go to prison or be stripped of his or her license in such a case. Eric Cropp was convicted of criminal charges in the absence of public support, except for Michael Cohen of ISMP. Whether this is right or wrong is a matter of opinion.
The pharmacy profession lost an opportunity to speak about patient safety systems, staffing issues, medication compounding practices, pharmacist to technician ratios, and other problems similar to those nurses have brought to public attention for years. In contrast, the TNA, and ANA used Anne Mitchell’s trial to educate the non-medical public about the patient safety advocate role of nurses. It is important to remember that the non-medical public is unfamiliar with common hospital practices. In my opinion, there is an expectation for professional organizations to educate the public on the scope of practice of its members. It is unfortunate that this opportunity was missed during the Eric Cropp trial.
Did a lack of support and public education lead to the setting of a disturbing precedent: the criminalization of medication errors? (Will the Criminalization of Medication Errors Make Patients Safer in Ohio?).
Eric Cropp was released from jail on February 15, 2010, and this explains the increased traffic to JParadisi RN’s Blog on February 16, in the aftermath of the Anne Mitchell case. It was only a coincidence. Whether or not pharmacists compare the two very different outcomes of these trials, I do not know.
I am married to a pharmacist. However, for most of my career, I was a pediatric intensive care nurse dedicated to saving the lives of children like Emily Jerry. I saw firsthand families devastated from losing a child under less unusual circumstances. The opinions expressed in this post do not diminish my sympathy or empathy for the family of Emily Jerry.
The Institute for Safe Medication Practices (ISMP) has published a follow-up article regarding the case of pharmacist Eric Cropp in the December 3, 2009 issue of Medication Safety Alert! Acute Care, Eric Cropp Weighs in on the Error that Sent Him to Prison. In this article, Eric discribes events contributing to the fatal error.
Eric Cropp is the Ohio pharmacist who is serving 6 months imprisonment as part of his sentence after conviction for the death of 2 year-old Emily Jerry. The child died after receiving a dose of chemotherapy mixed in a hypertonic saline solution by a pharmacy technician. My original post on this case, Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp or his Patient, discusses the circumstances of this catastrophic medication error.
For readers following this story, please read Eric’s version of the events leading to the error, which has devastated the lives of the Jerry family, as well as Eric Cropp’s.
I received this article in a Tweet. For those of you following my posts regarding pharmacist’s Eric Cropp’s sentencing and the criminalization of medication errors:
Is there a difference between medication errors and pointing a gun at someone and pulling the trigger? Are judgement and punishment decided soley by outcome? What part, if any, does intention play?
Although medication errors are not the focus of this blog, I feel it’s important that health care professionals know what is occurring in the state of Ohio, in the aftermath of the Eric Cropp sentencing referenced in this blog’s post Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp or his Patient (September 5, 2009).
According to the September 10, 2009 issue of The Institute for Safe Medication Practices, Legislation has been introduced in Ohio that would establish criminal penalties for pharmacists, pharmacy interns, and qualified pharmacy technicians who fail to report suspected dispensing errors with a “dangerous drug” to the Board of Pharmacy(legislature.state.oh.us%2fbills.cfm%3fID%3d128SB+119) Criminal penalties would include fines of up to $250 and 30 days imprisonment. Three or more convictions within 6 months would result in increased fines and up to 180 days imprisonment. The Board of Pharmacy would also be required to investigate all errors and pursue disciplinary action if warranted”
The article goes on to say
ISMP adamantly encourages reporting of medication hazards to promote learning. But you can’t punish people for not reporting errors and then subject them to punishment if they do report errors…Ohio pharmacy staff are ” damned if they do” and “damned if they don’t” report errors; in either circumstance, they face the very real threat of imprisonment, fines and a criminal record.”
Will this type of legislation create a safer environment for patients? Will other states follow suit? Will legislation such as this be applied to health care providers who administer medications, such as nursing instructors training students in clinical rounds, or nurse preceptors? (remember, pharmacist Eric Cropp did not mix the hypertonic chemo, a pharmacy technician did) Will it drive people away from careers in health care professions?
Read the full article at http://www.ismp.org/newsletters/acutecare/currentissue.asp
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.