Magazine article Drug Topics

RPh Second Victim in Ohio Drug Error

Magazine article Drug Topics

RPh Second Victim in Ohio Drug Error

Article excerpt

Eric Cropp was a victim of his own pharmacy error.

The former supervising pharmadst at Rainbow Babies & Children's Hospital in Cleveland is nearing the end of a six-month jail term after signing off on a misprepared chemotherapy treatment that killed two-year old Emily Jerry in 2006. Pharmacy techmdan Katie Dudash, who prepared the fatal dose, was not charged.

"This was a terrible injustice to the pharmacist," said Timothy Vanderveen, vice president of the CareFusion Center for Safety and Clinical Excellence. "This was not a criminal act, this was a system error. As so often happens, the clinidan involved has become a second Victim."

Vanderveen introduced a webinar examining the error that was led by Michael Cohen, president and founder of the Institute for Safe Medication Practices (ISMP). The fatal mistake was a compounding of an etoposide solution with hypertonic saline instead of normal saline, Cohen explained. Cropp failed to catch the technician's solution switch because there was no system in place that could have allowed him to spot and stop the hypertonic admix.

"I am disappointed with my colleagues in Ohio and their silence in this case," Cohen said. "I expected better of my fellow pharmadsts, I expected better of the judge, and I expected better of the Board of Pharmacy who, it has been said, acted like a kangaroo court.

The Board found no system errors on the part of the hospital, which was dearly wrong," Cohen continued. "The hospital pharmacy made significant changes to their processes and physical facilities since this error occurred. This was purely a tragic acddent, a system error. Like too many healthcare professionals who make mistakes, Eric has become another victim."

The error began on Sunday, Feb. 26, 2006. Cropp arrived at the pharmacy to find a computer system that had been offline for maintenance, a backlog of drug orders, a short staff, and an IV prep tech who was planning her wedding.

The IV prep area was cramped and crowded on the best of days, Cohen reported. JV preparation protocols were incomplete and not strictly enforced, and hypertonic sodium diloride was within easy reach. ISMP has long called for hypertonic solutions to be kept under lock and key or in a separate, hard-toaccess area to guard against acddental substitutions with normal tonic solutions. …

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