Jail Time for a Medical Error, Redux: The Case of Eric Cropp

Two years ago, I wrote about the case of Julie Thao, the Wisconsin nurse sent to prison for a medication error. I argued then that – although Julie bypassed some safety rules – she most certainly did not deserve jail time.

Along comes another case involving jail time for a medical mistake, this one featuring an Ohio pharmacist named Eric Cropp. I became aware of Eric’s case through the efforts of Michael Cohen, the endlessly energetic president of the Institute for Safe Medication Practices (and 2005 winner of a MacArthur “Genius” Award), who has championed Eric’s cause.

Eric was the lead pharmacist at Cleveland’s Rainbow Babies and Children’s Hospital on February 26, 2006. The pharmacy, understaffed that day, received a rush order for chemotherapy for a 2-year-old girl, Emily Jerry, who was undergoing treatment for a spinal malignancy. Emily JerryAn unlicensed and distracted (by press accounts, she was planning her wedding on the day of the event) pharmacy technician mistakenly mixed the chemo with 23% saline rather than the intended 0.9%. Eric, working in cramped quarters and rushed for time, gave final approval to the mixture, partly because, after seeing a spent bag of 0.9% saline next to the mixed solution, he assumed that it had gone into the solution. In other words, the case was a classic illustration of James Reason’s Swiss cheese model, in which numerous safety checks failed due to a confluence of systems and human errors. Tragically, little Emily died from the hypertonic saline infusion.

On hearing of the error, a Cuyahoga County DA decided that the case merited criminal prosecution, even though Eric had no history of errors in his pharmacy career and root cause analysis of the case confirmed that its cause was simple human error compounded by systems problems. At trial, fearing even harsher penalties, Eric pleaded guilty to involuntary manslaughter, and was sentenced to 6 months in the state prison, 6 months of home confinement, 3 years of probation, 400 hours of community service, and a $5,000 fine. Moreover, the Ohio pharmacy board permanently stripped him of his license, depriving him of his livelihood – forever. (The hospital was also sued, and settled the case for $7 million.)

During last week’s webcast, Mike Cohen described visiting Eric in prison. “Like a scene out of a movie,” he recalled, with Eric in his orange jumpsuit, speaking to visitors through a glass wall, other felons – including violent offenders – milling about. As he related the visit, Mike choked up with emotion, clearly seeing this tale as both powerfully tragic and cautionary.

I won’t reiterate my discussion from the Julie Thao case, except to restate my view that the criminal system should have absolutely no role in dealing with medical errors unless we are talking about cases of sabotage, or of willful and recurrent violation of safety rules when harm was foreseeable. By all reports, Eric’s case met neither of these criteria.

Instead, I’d like to place this case in the broader context of the patient safety field, weaving it together with my New England Journal piece last month on balancing “no blame” and accountability. I’ll also raise some parallels with national debates over mammograms and conflicts of interest.

As we approach the 10th anniversary of the patient safety movement on December 1st (more on that next week), one can feel the ground shifting – from our initial “it’s all about ‘no blame’” mantra to an environment in which accountability is being increasingly demanded of us. Part of my reason for arguing so strongly that we need to begin enforcing our own safety standards – particularly when we’re dealing with no-brainers like hand hygiene – is that the public is beginning to see our reflexive invocation of “no blame” as in-credible – as evidence of our unwillingness to address performance gaps, even when they are egregious. I worry that the more we appear to be looking the other way, the more likely we are to experience imposed solutions: by regulators, through tort law, or, most troubling, in criminal courts. Parenthetically, this issue feels a lot like our debate over healthcare conflicts of interest, particularly gifts and payments to doctors by drug and device makers. In both cases, our failure to police ourselves has literally invited outside intervention.

While the Cleveland case was partly driven by public concerns regarding patient safety, by all accounts, the trial’s outcome was also swayed by the emotional testimony of Emily’s mother, Kelly Jerry – an articulate, anguished woman who had lost her baby. How do we deal with the public emotion that is sure to well up in cases like this?

Interestingly, even Emily’s (now divorced) parents disagreed about the role of the pharmacist in Emily’s death. “Eric Cropp’s incompetence goes far beyond conducting one reckless act,” said Kelly Jerry, Emily’s mom. “[He] consciously disregarded any and every set standard of protocol regarding patient safety.”  On the other hand, Chris Jerry, Emily’s dad, said, “I feel very sorry for the pharmacist… This guy is facing a prison sentence, and I know it was an accident.”

Like the debate over last week’s mammography guidelines, Kelly Jerry’s testimony pitted science against emotion. I think it would be next-to-impossible to find a safety expert who believes that Eric Cropp’s mistake rose to a level that merited criminal penalties. Similarly, after reviewing the U.S. Preventive Services Task Force data, it would be difficult to find a dispassionate scientist who would argue that mammograms in low-risk women aged 40-50 have a favorable risk-to-benefit ratio (not to mention cost-to-benefit). Yet, politician after politician (many of whom knew better) literally sprinted to the klieg lights to denounce the Task Force and defend what we now know to be bad public health policy.

The point is that politics and emotions will always compete against science in public debates about critical health issues. Our job as experts is to do the best we can to explain the complex concepts (whether it is error theory or risk-benefit ratios for preventive services) clearly and honestly. But even when we do, on those hot button issues that stir up public passion, the political process is likely to win out. Whether the politicians and attorneys truly don’t understand the science or are simply pandering, it is always troubling to watch, and it was particularly sad last week to see the Preventive Task Force members, all good scientists trying to do the right thing, being thrown under the bus by Secretary Sebelius and others.

Similarly, it is natural for the parent, spouse or friend of a loved one who dies of a medical mistake to demand a pound of flesh, damn the Swiss cheese. In Internal Bleeding, Kaveh Shojania and I wrote about this, citing the wonderful book on medical malpractice by anesthesiologist Alan Merry and famed novelist Alexander McCall-Smith (yes, that McCall-Smith). The words ring true as we think about the case of Eric Cropp:

“It is to be expected that families or patients will blame the party holding the smoking gun, just as they would a driver who struck their child who ran into the street to get a ball. Some bereaved families… will ultimately move on to a deeper understanding that no one is to blame – that the tragedy is just that. But whether they do or not, write Merry and Smith, ‘It is essential that the law should do so.’”

In this case, the law did not do so. So, as your enjoying your turkey on this day of thanksgiving, please give a thought to the victims of this terrible tragedy, Emily Jerry and her parents.

And Eric Cropp.

26 Responses to “Jail Time for a Medical Error, Redux: The Case of Eric Cropp”

  1. menoalittle November 27, 2009 at 11:18 pm #

    Bob,

    Your coverage was superb.

    information germane to the case disappointingly not mentioned by you, but was in the ISMP commentary, is that it was a Sunday morning and the HIT devices were experiencing “unplanned downtime”. Directly from the ISMP report:
    “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).”

    This was not merely a “Swiss cheese model” event. The safety checks were thwarted by computer failure for which the hospital does not appear to have adequately trained its staff. The safety of the computer system and its back up was perhaps the “Swiss cheese”.

    Harm from HIT systems is foreseeable. No one want to admit this in a tech happy world, but the pharmacist and technicians were victims of a medical care delivery system that was disrupted by a defect in the HIT products that were purchased by the hospital.

    This bizarre case would never have occurred had the defect in the HIT systems not reared its ugly head.

    Here are a few questions honoring accountability. How many other patients suffered adverse events, if from nothing else but the delays in therapy? What was the back up system? When were they last tested? Do they run computer failure drills? Why was there not more help for these victims and the patients? Were the hospital administrators aware that their systems were failing? When did they fail and what did the adminstrators do about it? What did the hospital administrators do subsequent to this event as a lesson learned other than fire the pharmacist and technician?

    By not mentioning the computer failure as a sentinel actor, I must say with regret, you unintentionally (I hope) make a statement that depreciates the cause of patient safety. Moreover, you tacitly promote the ongoing HIT vendors’ invasion that is planting poorly designed and unregulated computerized care delivery systems that have and will, going forward, undoubtedly and repeatedly breach patient safety.

    Whenever we read of hospital wide HIT system failures, the story always provides a disclaimer from the hospital’s administration, “but patient care was not affected”. I have always doubted the truth of such self-serving statements, now borne out at the Rainbow.

    Readers may also be interested to read the coverage in HIStalk on August 17 and 31 of this year.

    Best regards,

    Menoalittle

  2. menoalittle November 27, 2009 at 11:22 pm #

    Bob,

    Good report. This story is a must read for all health care professionals being required to provide care using HIT systems.

    Information germane to the case disappointingly not mentioned by you, but was in the ISMP commentary, is that it was a Sunday morning and the HIT devices were experiencing “unplanned downtime”. Directly from the ISMP report:

    “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).”

    This was not merely a “Swiss cheese model” event. The safety checks were thwarted by computer failure for which the hospital does not appear to have adequately trained its staff. The safety of the computer system and its back up was perhaps the “Swiss cheese”.

    Harm from HIT systems is foreseeable. No one want to admit this in a tech happy world, but the pharmacist and technicians were victims of a medical care delivery system that was disrupted by a defect in the HIT products that were purchased by the hospital.

    This bizarre case would never have occurred had the defect in the HIT systems not reared its ugly head.

    Here are a few questions honoring accountability. How many other patients suffered adverse events, if from nothing else but the delays in therapy? What was the back up system? When were they last tested? Do they run computer failure drills? Why was there not more help for these victims and the patients? Were the hospital administrators aware that their systems were failing? When did they fail and what did the adminstrators do about it? What did the hospital administrators do subsequent to this event as a lesson learned other than fire the pharmacist and technician?

    By not mentioning the computer failure as a sentinel actor, I must say with regret, you unintentionally (I hope) make a statement that depreciates the cause of patient safety. Moreover, you tacitly promote the ongoing HIT vendors’ invasion that is planting poorly designed and unregulated computerized care delivery systems that have and will, going forward, undoubtedly and repeatedly breach patient safety.

    Whenever we read of hospital wide HIT system failures, the story always provides a disclaimer from the hospital’s administration, “but patient care was not affected”. I have always doubted the truth of such self-serving statements, now borne out at the Rainbow.

    Readers may also be interested to read the coverage in HIStalk on August 17 and 31 of this year.

    Best regards,

    Menoalittle

  3. Jim Conway November 28, 2009 at 1:33 pm #

    Bob, so tragic for the family, Eric and all involved. As I read it, I was reminded of key learning at Dana-Farber Cancer Institute in the aftermath of the chemotherapy overdose that killed Betsy Lehman. It became for me a mantra. “Our systems are too complex for merely extraordinary people to perform perfectly 100% of the time.” Our staff, no matter how good they are, suffers from being human. They will make mistakes. It is our responsibility as leaders to put in place a culture and systems to mitigate the chances of that mistake getting to the patient. All the public reports on this error report the absence of such a culture and system to support safe practice.

    I also learned in the Lehman overdose that we could have fired all the staff, or sent them to jail, and done nothing to reduce the chance of it never happening again. Good people working in a broken system.

    Eric’s imprisonment is a tragic demonstration of how early we are in this patient safety journey in the culture/systems of our healthcare organizations, in our understanding of accountability, in medical liability and the courts, and in public policy. Yet I am most worried that we will all fail to learn from this case, fail to ask the question “Could it happen here?” and be writing in a short time about another dead child, another devastated family, and another nurse, doctor, or pharmacist.. Instead of imposing the scarlet letter of accountability on this jailed pharmacist, will we do something about the fact that “Our systems are too complex for merely extraordinary people to perform perfectly 100% of the time?”

    Jim Conway

    SVP, IHI

  4. sqsyed November 29, 2009 at 2:04 pm #

    A very insightful and at the same time terribly heartwrenching case. I totally concur with Bob and Jim in that the time is now for all of us health care professionals to not only collaborate and promote change in health care accountability, but also to take charge of what we have expertise of..how to handle no blame vs accountability in a culture of safety.

    I just finished listening to this webcast from Carefusion and was wondering if there had been or can be an attempt to involve Sorrel King, a leading pioneer in patient safety, as well as a parent of a medication error victim, in this case. Perhaps a support group that include proponents of ‘change from a systems perspective’ as her while balancing accountability, can facilitate our drive towards a safe system with transparent accountability.. a culture that is safe for both the patients and their caregivers.

  5. Eric S November 30, 2009 at 7:57 pm #

    Just out of curiosity, what, if anything, did the various medical professional societies in Ohio do in response? How far were they willing to go to the mat for Mr Cropp? Would the Cuyahoga Cty DA have backed off if every single pharmacist, physician and nurse in the county (or state) threatened to not show up for work if he continued to prosecute the case as a criminal offense?

  6. sqsyed December 1, 2009 at 9:39 am #

    Eric, great comments! I too would be very interested in the answers..It certainly is food for thought!. Thanks again.

  7. Mike Cohen December 1, 2009 at 2:27 pm #

    Eric and Sqsyed: This is something that has bothered us all along. Basically, there has been no organized effort by any pharmacy or other healthcare associated organization of which we are aware – locally or nationally. We have been contacted by a number of individuals who have asked if a fund has been established and I have to answer that, to the best of my knowledge, the answer is no. In the past we have been involved or are aware of other cases where health professionals were charged criminally (Denver case, Wisconsin case, nurses in Winkler County, Texas, etc.) and it seems that colleagues always come forward with a support system, including setting up a fund. Not so here. Part of it no doubt is that information and facts are sparse. The Board order basically says that there were no system errors. So Eric has been blamed entirely for what happened. A thorough publicly available analysis of the event (with a license revocation and criminal charges one would hope it would have been done by outside experts) is not in hand. Admittedly, even our own analysis is not thorough. We based our findings on conversations with Eric, his attorneys, the hospital, the media, a trusted observer at the state board hearing, etc. It is also speculation on my part but I have heard from several individuals who told me that “after hearing from the Ohio State Board of Pharmacy” they believe Eric was in fact not fit to practice. Much of that is probably related to hearing about errors made subsequent to the tragedy, after he was fired and sought work in community pharmacy practice. According to Eric, these errors were order entry errors documented for training purposes to help him learn to use the new computer program. Two of 14 did reach the patient with the rest caught by the check system. This was over more than a 6 month period. Eric said that one involved a mix-up between 50 mg and 100 mg tablets of sertraline, which the patient brought back to the pharmacy before use, commenting that it had happened several times before when other pharmacists filled her prescription. This was also happening at a time when he was probably suffering from post-traumatic stress disorder (perhaps other steps should have been in place). At the Board hearing, Eric even told them that he was not in shape mentally to practice. But rather than a permanent revocation, he should have been given a chance to heal and show he could become a reliable, competent pharmacist again—an even better pharmacist, having gone through this experience. As for jail, Bob said it best: Eric Cropp is not a criminal.

    Mike

  8. SarahW December 1, 2009 at 6:49 pm #

    I don’t see why medical errors should be exempted from prosecution.
    If there is a legal standard of criminal negligence and the burden of proof is met by the prosecutor on behalf of the people, why would you single out a deadly medical mistake for protection?

    I don’t know the full story of defense or prosecution in this case, or any background details that may have contributed to a decision to prosecute.

    Making an error that kills, after reckless violation of a professional safety standard, isn’t necessarily just a tort. It can be a crime.

  9. Mike Cohen December 1, 2009 at 7:33 pm #

    Sarah W.,

    What “reckless violation of a professional safety standard” did Eric breach?

    Mike

  10. sqsyed December 2, 2009 at 11:17 pm #

    Hi Mike, thank you for your great insight into Eric’s unfortunate case.

    There are a lot of unanswered questions still in this case and it really seems as though an example or statement was made out of Eric’s prosecution, by both the board as well as the DA. There are a lot of why’s here. Why the board looked at his training performance and used it to seal Eric’s fate?? Why testimony from his coworkers was considered unimpressive? etc.. These things simply don’t add up.

    I also know that everyone of us can’t even begin to imagine the parents’ plight.. we all share their sorrow and heartache.

    The question here is not on whose side are we, in fact, we are on both sides. We want to be proactive instead of reactive and herein lies the challenge..

    Mike.. I have suggested the following recommendations on my blog, (again my humble opinion):

    1. Create a team/system of legal proceedings that has in-depth knowledge and expertise of the health care dynamics and can address the needs of both the partners..patients and caregivers- They can serve as consultants and provide the framework for a “just & fair health care system”

    2. Create a national transparent system of accountability for health care errors, both medical and non-medical

    3. Develop a national framework for ensuring a Culture of Safety- harmony and partnership for both, the patient and the caregiver, partners in health care

    Hi Sara W.,

    I too concur with Mike. There are no professional standards, at least that I am aware of, for compounding medications. The only standard that all pharmacists and techs are taught and trained in is Aseptic Technique, USP 797, etc..

    It is interesting to note that the Board was also “watching” Eric after his termination and subsequently collected evidence against him. Is this a professional standard of operation for a Board of Pharmacy?

    Now, let us look at another scenario,

    Pharmacist A is supervising a technician in IV compounding. The tech is supposed to add a certain amount of insulin to the IV bag. This is a busy IV Room, with the same problems as most pharmacies: under staffing, tech problems, ambiguity in standard operating procedures: there are no clear cut guidelines for preparations etc..
    The tech has two vials of insulin out since she is preparing the IV;s from the label run. Pharmacist A ensures and repeats the dose of insulin required as well as the type of syringe to use. Since, it is a busy day, the pharmacist is delivering other Stat IV’s while the tech is preparing them, answering the phone etc.

    Pharmacist A comes back for the Stat IV bag with Insulin. He checks the bag against the insulin vial as well as the syringe. Everything is ok. Pharmacist A again verbally confirms from the tech the amount of insulin used. The tech replies in the affirmative.

    As he is about to leave for delivering of this IV with Insulin, Pharmacist A remembers that there has NOT been any other order for Insulin, why then are there two insulin vials? He returns back and checks again, step by step with the tech..

    Findings: Wrong dose was used!!! At least 10x the ordered dose.

    Result: A significant NEAR MISS was averted. Patient care was not compromised.

    Question:

    1. Will Pharmacist A report the near miss to his supervisor?

    2. Will Pharmacist A report the near miss to his co-workers?

    3. Will Pharmacist A recommend orientation and training of all IV Room personnel to prevent further errors? near misses?

    4. Will Pharmacist A/Tech post relevant information pertaining to this incident in the Pharmacy, to serve as Lessons Learned for others?

    5. Will Pharmacist A recommend and collaborate with Med Safety to look at high risk medications and their preparation standards, etc?

    My humble opinion: Pharmacist A does not want to get fired, does not want his license revoked or suspended, Pharmacist A also does not want this incident to be held against him/her for future promotions etc..

    So, my answer would be NO to all the above questions…

    What do you all think will be the answers??

    Seema Syed

  11. sqsyed December 2, 2009 at 11:55 pm #

    Sorry correction to the following:

    Result:

    A significant MEDICATION ERROR was averted and a NEAR MISS occurred.

    Thanks:-)

    Seema Syed

  12. ElizaG December 5, 2009 at 7:12 pm #

    I can’t pretend to have the experience or fancy “book-learnin’” of the many who post here. I do have what I hope are honest questions that I will attempt to ask in a reasonably intelligent way.

    Errors by humans in other industries often are subject to loss of livelihood and/or criminal prosecution. These errors don’t even have to result in death or injury. Recently, two airline pilots lost their licenses because they were distracted and overshot their destination by quite some distance. Individuals who text while they drive and cause injury and death to others are prosecuted criminally. Their errors are also distraction (stupid, but really – they never INTENDED to hurt anyone). The pharm tech who was distracted by planning her wedding never INTENDED to kill a child. The pharmacist himself who was overwhelmed with an unfair workload never INTENDED it either. The hospital that failed to staff the pharmacy adequately never INTENDED a child to die. Why is “intention” the standard for criminal prosecution with medical error, but not with other errors in judgement in circumstances outside of medicine?

    The distractions in the other examples are certainly gross negligence. Why are the distractions and errors in judgement by the institution leading to the error in this case not also gross negligence?

    Why exactly are healthcare personnel exempt from the consequences of their mistakes? The answer I hear from others posting is that if we don’t exempt them then they will not report their mistakes and the systems that caused them will not improve.

    Is the hospital involved now staffing the pharmacy more fully? Did they learn from their error enough to now put enough personnel (paying enough to have skilled enough staff) in place to keep this tragedy from happening again? Did they pay enough in their malpractice settlement to teach them that it is wiser to invest their money on the front end by hiring enough people, paying enough for well qualified, skilled individuals? Or, as is more likely the case, does the settlement represent “the cost of doing business.” That is, it costs less to settle this one case (and the few others that may come along later) than it would cost in the longer term to invest appropriately in systems and personnel to ensure that nothing even close ever happens again?

    One answer proffered here is that this pharmacist or indeed any other healthcare provider making a similar mistake has already learned his lesson and living with the knowledge of the consequences of his action is punishment enough, and will make him a better pharmacist. But, in other places I have heard time and again that practitioners make mistakes – that they cannot be expected to be perfect – that it is the nature of the art of medicine. The message I hear is that practitioners can carry on assured in the knowledge that it wasn’t really their fault. Mistakes happen. Note the use of the passive voice in these statements.

    Furthermore, why then wouldn’t our distracted pilots be given the same courtesy? By this argument they will be better at their jobs from now on. Indeed, using this standard, our texting teens should also be forgiven, secure in the knowledge that their actions resulting in the tragic death of innocents will now make them forever good drivers.

    It seems that healthcare practitioners want it all. They want to be allowed to make mistakes, not be subject to censure, prosecution or malpractice (because gosh, mistakes happen, we can’t expect perfection) and not have anyone except a few insiders know about it. You want us to trust you to fix it privately, behind closed doors, protecting everyone involved. You want us to trust you, but you don’t think we’re smart enough to understand the complexities of the system in which you operate. You want to be special. You want to operate above the law with your own set of secret rules.

    For the record, I am swayed by the argument offered by Dr. Wachter that the pharmacist did not deserve to be criminally prosecuted. And, I still have all these questions noted above, and the following:

    If you had it your way, what would have been the punishment (if any) in this case? And,

    did the pharm tech enjoy her wedding, knowing that the planning of it caused the death of a child and the ruin of a man?

  13. PookieMD December 9, 2009 at 9:01 pm #

    Wow, what a horrific case all around. The criminal prosecution of the pharmacist is unwarranted. Putting the pharmacist in jail doesn’t change the system, or make a similar error less likely to happen. I have to disagree with Eliza–with her texting teen analogy. Thanks for bring to light this sad case.

  14. Linda December 11, 2009 at 6:23 am #

    I left hospital pharmacy specifically for this reason.

    Ten years ago, I was the sole pharmacist at 7AM (the other one called in sick), I had 6 hours of orders from the ICU they were barking for me to enter, OR was calling for items the other pharmacist would have been responsible for, the other units had orders due in an hour, I was supervising 3 techs and oncology was calling for the first 2 chemos that hadn’t been checked for dosage accuracy, appropriateness against labwork because the night pharmacist was overwhelmed and ………….. when I called my director, he told me the next pharmacist was scheduled in at 9AM & I could do fine until then. He was not willing to come in himself.

    I have sat in on M&M’s and management meetings and sadly, it is assumed that 4-5% of the operating budget of any department at any time is devoted to settlements of this kind. Most are not of this magnitude, but when I have listened to this rationale, I realize that my value to the organization is not what I’m paid. They assume that 5% of the operating budget of a hospital pharmacy (not just my salary) would go to individual or system failures.

    That day, ten years ago, was a system failure. I dealt with it by telling oncology they would wait. They yelled and threatened and wrote me up. But, I chose to deal with OR & ICU first. When I had time, I did what I had to do for the oncology orders.

    But – I realized, the system was never going to be fixed. I had been a hospital pharmacist for 20 years. No, Eliza, the hospital administrators will not hire more nor more experienced pharmacists. They get by on bare bones and raw hope that we will always do our best, which mostly is accurate and correct. However, in this case – as with the case with Betsy Lehman, which was a resident physician error – our best is sometimes not accurate and correct.

    I chose to leave that environment rather than have a death result in the end of my career. I’ve known many pharmacists who have made errors which have resulted in severe harm and death. None have been prosecuted and none have lost their licenses – but, none have resumed the practice of pharmacy. It is far too painful and once your confidence in yourself is lost, it is never regained.

    Should this pharmacist have gone before the Board? Yes. Many factors go into the revocation of a license and there were mitigating factors that may have played into that. By revoking his license, the public is protected.

    Should this pharmacist have been sued for negligence or malpractice? Probably. These are civil issues which our court system has methods to deal with. Monetary sanctions are normally the end result and serve to provide a punishment severe enough to prevent further individual or system harm (altho in reality it does not). How much was this child’s life worth? There is no amount of money for the loss of a child, but the parents settled with the hospital for $7million. There doesn’t seem to be any evidence there was a suit against the pharmacist. His fine was to the Board, not the parents.

    Should this pharmacist have been tried in criminal court for involuntary manslaughter? Apparently the mother felt yes, but the father did not. What result did the mother expect for the pharmacist to be incarcerated? Did that make the public safer, the hospital systems safer, the memory & purpose of her daughter to survive, the pharmacist to be punished more severly? I would say no to all. The pharmacist, as with almost every pharmacist who commits negligence will never return to practice and will suffer the rest of his life, not because he is now a felon; rather because his actions resulted in the death of a patient. The hospital will not change its systems (notice – the same systems which contributed to this error have contributed to errors more than ten years ago). Perhaps the mother is more comforted now – we cannot know if pursuing negligence proceedings was not enough & she actually needed to have him become a felon for the rest of his life. If that is the case, she is not just sorrowful and one to be comisserated with, but she is also vindictive.

    Perhaps the fact the parents divorced over this event is telling. It is not uncommon to have parents separate and divorce when a child has a potentially fatal illness. However, to add vindictiveness and revenge to the mix does not help anyone’s situation.

    In my experience, the situation is as precarious now as it was ten years ago with me and as it was with this family. Fortunately for me, my years of experience allowed me to withstand the resultant disciplinary actions against me because I forced oncology to wait. Younger or fearful pharmacist will not make that choice.

    I too have moved on to the outpatient setting. You, the public, are probably more vulnurable in this setting that in a hospital. There is tremendous pressure in the outpatient setting – not just from the administration and employess as with inpatient, but from you – the public. You want it now & don’t want to wait the 20, 30 or 60 minutes I tell you it will take. You think we overcharge when we need to compound Tamiflu for your child, but this takes opening capsules, weighing out the exact amount, solubilizing it then mixing to the exact volume so the dosage is correct. But, I am inundated by phone calls, you telling me you need to pick up your other child and can’t wait 30 minutes & need it now, people from out of town who have medication in lost luggage, people wanting to transfer prescriptions so they can get a $20 gift card – all manner of interruptions. Then my corporate people want to know why I told you to wait when you complain. Was that $20 gift card worth risking your health????

    In 30 years as a pharmacist, I’ve never experienced an environment so fraught with error prone systems as I’ve seen in the last 10 years. It is everywhere & the lesson is – you never want your surgeon to hurry nor to be his last patient of the day. The same holds true for your pharmacist.

  15. PJ December 11, 2009 at 4:14 pm #

    The thought of sending a health care professional to jail for making a mistake is chilling. It needs to be pointed out, however, that we don’t actually know the full story here. We don’t know the details of the Ohio Pharmacy Board’s proceedings, nor do we know the details from Eric Cropp’s presentence investigation. We can speculate all we want on the family’s vindictiveness and political influence, but at the end of the day we are judging without really knowing.

    Take it from someone who has been there: It is incredibly difficult to be on the receiving end of a medical error that leads to injury. A nurse’s unintentional mistake and subsequent coverup literally almost cost me my right arm. I sympathize with her, I really do. I know she didn’t mean to botch the procedure – but once it happened, she had an ethical and professional responsibility to, at the very least, notify the doctor and document it in my chart. She didn’t, probably because she was scared. But I ask you: Was this right? Was it safe? Was it ethical?

    Sad to say, I had to file a written complaint with the hospital twice before getting any kind of response. The upshot was they couldn’t tell me anything about what happened, they point-blank refused to pay for any of the subsequent surgery and their so-called patient relations representative was appallingly hostile and rude, as if I were in the wrong for having the gall to expect them to be accountable. (I am not making this up.) I’m a nice person so I didn’t push the issue, nor did I sue… but I should have. And I don’t think this experience is all that uncommon.

    I read this entire post and the following comments with very mixed feelings. It seems to me that much of the dialogue about patient safety is happening among the health care professionals. I don’t think this is a bad thing, and I’m actually very glad to see the progress that has been made. But I think there’s still a huge gap between what you profess to believe about accountability, and what an injured patient or bereaved family actually experiences. In spite of what you say, you don’t really want to hear from us, because it makes you uncomfortable. We have comparatively little power, so it becomes easy to dismiss us as ignorant or demanding or vindictive and to exclude us from the table. Many of us are none of these things; we just want to be trusted enough to be part of the conversation.

    I seriously think you need to find a way to narrow this gap, because I’m not sure how much longer the public is going to be willing to tolerate it. And I totally agree with Dr. Wachter. If you don’t have the collective will to address it, don’t be surprised if outside solutions are eventually imposed. I would rather not see this happen… but your track record of being open and honest frankly isn’t good enough to make you trustworthy.

  16. TC December 11, 2009 at 9:24 pm #

    I understand the public who comes to a healthcare professional for any procedure, treatment or medication expect it to be done or dispensed perfectly each and every time. We all know that because human beings are performing the tasks required that there will never be any task that is performed perfectly every time. When we trust ourselves or family members to a physician, nurse or pharmacist we are, whether we want to accept it or not, taking some major risks. We are risking that the human who gives us the pill or infusion, or performs the surgery or other procedure will perform it correctly. If it is not done correctly or if the incorrect pill or infusion is given to us there may be harm or possibly fatal. The judge, members of the jury or even the family members of this child if they were behind the counter or in the IV room would face the same possibility of making a mistake as Eric Cropp even if they follow every guideline for safety and prevention of errors that is written. The only way to avoid this is to not use humans.

    I agree 100% that we need systems and vigilance to guard against as making any kind of error. I do not advocate that since we are human we will make mistakes so lets just do the best we can and accept the consequences. I’m just not advocating sending the pharmacist to jail if he has followed the system that was in place and he was performing all of his procedures correctly to the best of his ability. Sometimes that is unjust.
    Now to go back to a previous comment, if the pharmacist had been texting or doing things that were distracting him from his duties and he made an error, that is another story.

  17. RN December 14, 2009 at 11:57 pm #

    I totally can sympathisie with all the postings here. As a patient I want the safest care..illness is bad enough without errors and untested medications complication things. Hospitals are constantly putting patients in danger. Systems are ridiculously complex if you ever try and process map any of them. Nurses are constantly being expected to care for more and more patients with less assistance. Without safe staffing laws we are all in danger. A collegue recently remarked regarding the state of the professiion in many areas is : “the only thing worse than being a nurse..is being a patient.” As a pedi nurse in a teaching hospital I literally catch 2-3 med errors a week made by residents.. I wonder how many get past me or how many I inadvertentingly make when I am made to stay OT when I am exhausted or made to take another pt before I have finished all the discharge process of another… it is scary..and its all about money! until insurance companies are made to pay specifically for pharmacy and nursing services (separate from the room rate), hospitals will continue to cut these professionals for the bottom line and endanger patients and staff alike

  18. ElenaC December 17, 2009 at 8:35 pm #

    In response to ElizaG’s suggestion that the pharmacist’s situation is equivalent to: “Individuals who text while they drive and cause injury and death to others are prosecuted criminally. Their errors are also distraction (stupid, but really – they never INTENDED to hurt anyone).”

    As Dr. Wachter says: “Eric, working in cramped quarters and rushed for time, gave final approval to the mixture, partly because, after seeing a spent bag of 0.9% saline next to the mixed solution, he assumed that it had gone into the solution.”

    In other words, Eric was trying to do his job under difficult circumstances and made a mistake. The individual who texts while driving is not ‘trying to do his job’, which is drive an automobile. The driver CHOSE to text while driving, an activity that has been proven to put others at risk. That is a criminal offense while Eric’s circumstance is due to human error and systems failure.

  19. Tar-heel December 18, 2009 at 7:13 pm #

    Thanks for the kind words work toward understanding and compassion for Eric Cropp. As his friend I know this has been hard on him and he was tried in the press due to misinformation. He has recently been denied shock probation and will have to serve the full sentence.

  20. Hugh F. Hill III, MD, JD January 10, 2010 at 5:56 pm #

    Just came across this thru Kevin.com. I agree that system problems are more likely to be identified and corrected in a less threatening environment, but the horror that we providers feel on reading of this stems from 2 sources: First the reportage suggests that this was vicarious criminal liability, and second, we can all imagine deconstructing our own bad outcomes and finding errors and omissions a plenty. Let me also suggest that inconsistent application of these penalties makes them feel more frightening and infuriating. Prosecutorial discretion, if not wielded fairly, can undermine necessary public support for the justice system. In our area, we recently had a man freed on DNA evidence decades after a prosecution. The trial judge is still on the bench and he angrily berated the prosecutors, but none of the prosecutors, investigators, or judges are going to jail.

  21. Bob Wachter February 18, 2010 at 6:06 am #

    Eric was apparently just released from jail this week — here’s a CNN report on the case, with an interview of a tearful Eric Cropp.


  22. LeeTilson February 24, 2010 at 7:44 pm #

    No one believes that ordinary mistakes should be criminalized. My conversations with some of the parties lead me to believe that the misinformation about the Emily Jerry case in news reports is rampant. Currently, I am trying to get a transcript of any court room and pharmacy board proceedings. The online database for the Cuyahoga County Courts includes the criminal proceedings, but no civil case as has been reported here and elsewhere.
    http://cpdocket.cp.cuyahogacounty.us/TOS.aspx
    I will try to share the information I receive.

    While I certainly understand the sympathy expressed for the pharmacist, I do not understand the total absence of concern expressed for the Jerry family, or the families of the patients who are injured or die every day from similar errors.

    A search of PubMed for “medication errors” generates over 500 articles per year on the subject for each of the past five years. I cannot understand why we allow this problem to persist.

    I applaud the empathy and concern expressed for the pharmacist. When we are as empathic and concerned over each of the victims, the solution will be found.

    Emily Jerry was a wonderful child. And like this pharmacist, Emily Jerry will never be able to work in a pharmacy in the future.

    Lee Tilson
    http://www.rethinkingpatientsafety.com

    rethinkingpatientsafety@gmail.com

  23. LeeTilson March 3, 2010 at 2:06 am #

    Two factual updates.

    First, on page 4 of its recent newsletter, the Ohio Board of Pharmacy claims that there is significant misinformation about its recent decisions. I am trying to pin this down.
    http://pharmacy.ohio.gov/sbn2010-02.pdf

    Second, it is frequently claimed that this pharmacist was stripped of his license because of this one human error. I found this document online that appears to indicate that this is inaccurate. There were at least fourteen other errors of some significance.

    http://pharmacy.ohio.gov/rphquery/pdfs/03319886.pdf

    I will continue looking for information.

    Dr. Wachter, I appreciate your devotion to the cause.

    Lee Tilson
    http://www.rethinkingpatientsafety.com

  24. Jenna April 8, 2010 at 1:10 am #

    This is such a classic case of a medical professional making a mistake, refusing to admit it, and blaming “the system”. “We’re only human,” those who provide us with medical care claim, then absolve themselves of basic human decency.

    I do not work in medicine. However, the job I have does place me in a position of responsibility for vulnerable people. People in my field make far less money than doctors, nurses, or pharmacists and typically work under far more stressful conditions. Nevertheless, it doesn’t matter how many hours in a row we work, how incompetent our employer is, how much pressure we’re under — we are responsible for caring for our clients. If we fail to do so, we face loss of licensure, civil and criminal penalties. If we’re short staffed, or if the next shift doesn’t show up for work, I have to make up the difference until relief shows up. It’s not fair to me as an employee, it’s not best for client safety for me to work 24 hours straight, but SOMEONE has to be responsible. If a client died as a result of my negligence, I WOULD feel terrible for the rest of my life. However, I would also be barred immediately from my profession and, depending on the circumstances, arrested. I can guarantee that Eric Cropp does not have a better developed conscience than I do; he just has his master’s degree in a different subject. The man killed one child, then harmed at least one other; it’s safe to assume he wasn’t going to recognize his own incompetence without outside help.

    In my field, service to clients — not the careers of those who provide services — is paramount. As a result, most of us avoid working for employers who engage in practices that jeopardize client safety. I’m astonished that so many nurses and pharmacists have posted, saying the conditions they work under are similarly pressured and dangerous, that fatal errors are inevitable because of “the system”. Slavery’s been illegal for some time now; if you continue to work under conditions that put your patients at risk, you’re part of “the system”. Refuse to be part of it anymore. Move to an area that has adequate legal protections for patients. Take a pay cut to work for an ethical employer. Organize with others in your field. And for God’s sake, stop saying the victims of your “system” are the PROBLEM, that if only they and their families would stop protesting the injuries and death, things would be great.

    • C. Kleinhenz, RPh, Esq. November 21, 2012 at 11:16 pm #

      You do not state what your “job” is, you acknowledge your lack of knowledge of the healthcare system, you are not a risk manager, and you hold no special knowledge of the case. As an attorney and pharmacist, I can assure you that there is an abundance of support for the notion that the “system” you so aptly label is in fact a much larger entity, and in fact emcompasses the entire healthcare distribution network. Please read the Institute for Safe Medication Practices (ISMP) position paper so you have a modicum of foundation to assess this case in particular and, more globally, medical malpractice.

  25. Kay Grames September 18, 2010 at 12:06 am #

    I’ve just learned about this case. Having lost a child myself, I feel for the parents. Having attending support groups for bereaved parents, I’ve witnessed the raw rage that Emily’s mother evidently struggled with too.

    But I am heartsick over the destruction of a good man who made a mistake that any trained professional could make – and unfortunately does make – under these conditions.

    THAT is the tragedy that could have been easily avoided and was not.

Leave a Reply