Revisiting the Eric Cropp story and safety in medicine

One of my more popular posts to this blog was about Eric Cropp, the pharmacist in Ohio who wound up actually facing criminal charges after the death of a pediatric cancer patient under his care. I made that post back in 2009 August, back when this was my personal blog and not yet called Rant Roulette. So it’s high time I re-visit the story and what has happened since then, and some other healthcare-related matters. This is going to be a long one, because a lot has gone on since the original post.

First, if you haven’t seen it before, is Eric Cropp being interviewed by David Mattingly of CNN. You may want to skip this if you are easily disturbed; I found it quite difficult to watch myself. Conveniently, they pair this with an interview of only Emily’s mother, Kelly Jerry, not her father, Chris Jerry. The distinction is important, as noted below.

This post on Philly.com’s Check Up blog describes some of what has gone on since then. The post dates from 2011 November, during a period I was not very active posting to this blog. Quoting the post:

As I wrote in a previous blog that touched on this case, I completely understand the angst and the call for retribution by families left behind in the wake of a fatal medical error. I also recognize they need someone to blame and to hold accountable for the pain of their horrific loss. But I truly admire one family member who took a different path, Chris Jerry, Emily’s dad. Almost from the start, he opposed Mr. Cropp’s jailing, and now he’s even forgiven him. In fact, Chris Jerry and Eric Cropp have been working together, traveling around the country to speak at pharmacy meetings to help create awareness of the vital importance of safety practices. I’ve received several emails from colleagues around the country who’ve attended these programs—enthralling is how they describe it.

(Contrast Chris’s attitude with that of Emily’s mother, Kelly Jerry, who was and is all too willing to hang Eric Cropp out to dry.)

The story goes on to mention the Emily Jerry Foundation, which is dedicated to increasing patient safety by minimizing the human error in medical treatment, started shortly after Emily’s death in 2009.

I applaud Chris Jerry for first, realizing that throwing Eric in jail really doesn’t solve anything, and second, for forgiving him for what could be said wasn’t really his fault, even if it was legally his responsibility. I say it like this because of this comment made by The Redheaded Pharmacist on a post about the Eric Cropp case by The Blonde Pharmacist:

I worry about the working conditions for pharmacists after reading these stories: long hours and no breaks have to play a role in some of the mistakes that are being made in pharmacies around the country. The problem is that if an incident does happen, it is usually the pharmacist and not the employer that takes the blame and the fall for what happens. I’m not saying pharmacists are without fault and should avoid responsibility for their mistakes while on duty, but to place the full blame with them seems to be a bit short sighted. At some point, reducing hours, [increasing] workloads, and no breaks have to play a role in the incidence of errors but the employer will simply bring in another pharmacist and move on if the one on duty is disciplined.

The ISMP’s article has the rather derisive-looking headline “Ohio government plays Whack-a-Mole with pharmacist”. Indeed, without reforming the system, and just sending the pharmacists and other healthcare professionals off to jail or just revoking their licenses, it’s just a game of Whack-A-Mole, or treating the symptoms without curing the disease. Quoting the article:

No matter how hard we try, human endeavors carry inherent risks. We can try to do everything possible to make it safe for patients, but we often fail to plan for the unexpected—a computer system that is nonfunctional when you arrive at work, causing a serious backlog of work; an inadequate level of staff on duty because of unexpected absences; a distracted technician working in a hectic high-risk IV area—just a few of the unexpected conditions in Eric’s case on the day of the event. As Marx notes in his book, civil, criminal, and regulatory systems are increasingly obscuring the differences between intentional, risky choices and inadvertent human fallibility. Thus, the net cast to catch criminals is now catching those whose only crime is that they are human. The criminal courts are playing the most extreme version of Whack-a-Mole with the lives of all healthcare professionals, for who among us cannot say, “It could have been me” when thinking about the plight of Eric Cropp and Emily Jerry?

(The article is aimed at healthcare professionals, so that’s who the “us” is referring to.)

Until it’s standard procedure for the workflow of healthcare professionals–pharmacists in particular–to allow for normal work and meal breaks, until nurses don’t do just plain stupid things like call in chemotherapy orders hours early so the pharmacists feel rushed to check the solution so it can be dispensed (like Emily’s nurse did), until pharmacy computer systems are reliable so they don’t go down for hours at a time (like they did at Eric’s pharmacy), this is still destined to happen again to someone, somewhere.

And there are other situations similar to this. This entry in HealthBlog refers to this story about mis-mixed colchicine involving Gary D. Osborne and his company, Apothécure, in Dallas, Texas. (Steve at HealthBlog does not link to this latter story, it’s possible he intended to but the link in the article goes to an unrelated story.) Gary Osborne has just as much nominal responsibility for his employees/assistants as Eric Cropp did when his assistant mis-mixed the chemotherapy for Emily Jerry. The Food and Drug Administration’s Office of Criminal Investigations (FDA-OCI) findings pursant to their investigation were that Gary and his company committed two violations of the Federal Food, Drug, and Cosmetic Act (FDCA) due to some colchicine vials containing a lethal dose.

While there is some relief that at least the Justice Department and the FDA-OCI understand it’s merely human error and are only charging Gary and Apothécure with misdemeanors, it’s still troubling that a human error is being pursued under criminal law at all. It’s as if nothing was learned from the Eric Cropp case, or what was learned is being willfully ignored.

I strongly believe criminal prosecution should be reserved only for the most egregious of offenses, where there is a repeating pattern of conduct which endangers human life. Are there cases where criminal prosecution is the most fitting remedy? Yes. Does a shipment of two bad lots of colchicine qualify as such an egregious offense? Probably not. If it had been a repeat pattern over a longer period of time of substandard quality control, then criminal prosecution would make more sense to me. In this case, I don’t think Gary or Apothécure should be subject to more than a civil or administrative penalty.

Quoting Steve’s Healthblog post:

This was also dealing with a compounded drug… we all are aware of how the FDA is AGAINST Pharmacist compounding… could these criminal charges – 5 years after the fact be at the prodding by the FDA to the Justice dept?

If the FDA is pursuing this only to advance its own agenda against compounding pharmacies, it’s despicable and abhorrent. Especially when there are so many other areas of healthcare that need more aggressive and stringent regulatory oversight.

There’s another great post in HealthBlog which shows where the priorities really lay for at least one pharmacy. Hint: it’s not about patient safety, or customer service. Quoting the post:

[…] [T]he chain store where [another pharmacy blogger] works… puts anyone wanting a flu/vaccine shot AHEAD of all waiting Rxs.. […] WHY??? because … giving flu/vaccine are MORE PROFITABLE to the chain than filling the typical prescription(s).

In all honesty, this kind of thing should be illegal, and the pharmacy chains doing this should be hit with huge monetary penalties. This is the most despicable, horrendous, and egregious thing I have ever heard of in our healthcare system! It’s a shame that the blogger in question does not (and cannot, lest he risk his job) reveal which chain pharmacy this is with this insane policy.

When an otherwise good pharmacist like Eric Cropp loses his license and goes to jail after what is, in all honesty, one really bad day, and we have pharmacists willing to go along with ludicrous policies like this, it’s a wonder we don’t have more meltdowns in our healthcare system.

I fear the message we are sending to would-be pharmacists is this: Sure, become a pharmacist. Work 12 hour days with no rest breaks, let alone meal breaks, and take all the blame when one of your technicians screws up despite your best efforts to check his/her work. And if you’re really unlucky, you make a mistake (due to the work conditions setting you up for failure) and someone dies, you could actually go to prison and lose your license (like Eric Cropp did) while the technician that actually made the mistake walks free.

(There’s another way to look at this, too. How many other pharmacists around the US have made a mistake resulting in someone’s death in the past 20 years? I would be willing to bet most of them didn’t go to jail for their mistakes. So, if we assume for the moment that Eric Cropp’s imprisonment was just, that means that untold numbers of pharmacists out there got away with it.)

In light of this, who will want to become a pharmacist today? What happened to Eric Cropp is just the beginning of setting us up for a serious shortage of pharmacists within the next 10 years, if not sooner. We can’t wait 10 years to realize we have this kind of a problem. The time to start is now.