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.
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?
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.