Eric Cropp Talks to ISMP about the Medication Error Leading to a Child’s Death

     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.

Eric Cropp, Medication Errors, and Pointing a Gun at Someone’s Head

photo: JParadisi 2009

    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:

Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp and his Patient

Aftermath of the Eric Cropp Sentencing: Will the Criminalization of Medication Errors Make Patients Safer in Ohio?

Mistakes are Judged by Their Outcomes

      Read this article Former Ashville Fireman gets 4 Months for Shooting at Cyclist  and see what you think.

http://www.citizen-times.com/article/20091120/NEWS01/911200352

     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?

Aftermath of the Eric Cropp Sentence: Will the Criminalization of Medication Errors Make Patients Safer in Ohio?

     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 

    

 

Not a Wonderful Life: No George Bailey for Pharmacist Eric Cropp or His Patient

     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.