Magazine article Drug Topics

Former Pharmacist Indicted for Manslaughter after Med Error

Magazine article Drug Topics

Former Pharmacist Indicted for Manslaughter after Med Error

Article excerpt

An Ohio grand jury has indicted pharmacist Eric Cropp for manslaughter and reckless homicide in the death of a two-year-old child, which resulted from an improperly compounded IV solution. Both charges carry penalties of up to five years in prison.

The medical error occurred last year at Rainbow Babies & Children's Hospital where the child, Emily Jerry, was a patient undergoing chemotherapy. According to testimony presented before the Ohio board of pharmacy, the prescription for etoposide with a base solution of 0.9% sodium chloride was instead compounded by a technician with a base solution of 23.4% sodium chloride. Three days after receiving the medication, the child died. The grand jury declined to indict the technician, Katie Dudash.

"Our hearts go out to the parents and everybody who was involved in this tragic situation, including the healthcare workers, but we have to learn from our errors," offered Bona Benjamin, B. S. Pharm., director of medication use quality improvement, at ASHP. "When we punish someone for making an error, it discourages others from reporting errors. We need to change the system. I'm hopeful that we can find something meaningful in terms of safety from this child's death."

Punishment or prevention?

The prosecution has caused many medical error experts to worry that the focus is being turned from preventing errors to punishing pharmacists for making errors. Both Cropp and Dudash were dismissed from the hospital and from subsequent jobs at chain drugstores. In addition, in April the Ohio State Board of Pharmacy permanently revoked Cropp's pharmacy license.

"I am having a hard time understanding why this would warrant criminal charges," commented Michael Cohen, president of the Institute for Safe Medication Practices (ISMP). "Focusing on the individual is unlikely to have a positive effect in the long run. I have not read anywhere that he purposefully tried to hurt the patient."

Ernie Boyd, executive director of the Ohio Pharmacists Association (OPA), worried about the lessons that will be drawn from the incident. "This sends a very dangerous message to our pharmacists and all healthcare providers," he explained.

The biggest risk, Boyd, Benjamin, and Cohen agreed, is that the prosecution may inhibit pharmacists from reporting errors. …

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