Superstition and the safe landing of Flight 666 to HEL on Friday the 13th

Okay, so this is already a bit old (I intended to wrap this up around January 25th, and really, really let it slip), but it still deserves a short piece on it. Incidentally, I think the research I did on this one is worth the wait.

Ordinarily an airline flight is nowhere near being a newsworthy event. Planes take off and land successfully on an average of more than one per second around the world–over 100,000 flights according to this blog post by Gunner Garfors. The only times a flight is newsworthy are when one or two people wind up being the only passengers on the plane, or when a flight is affected by an incident (which need not be an outright “crash” to qualify as newsworthy).

This flight, however, made the news for an entirely different reason. It was Flight 666, which Christians regard as “the number of the beast”, destined for the airport in Helsinki, Finland, airport code HEL. And it took place this past January 13, which was Friday the 13th. Despite just about every superstition saying something would go wrong, nothing did.

Of course, that raises a lot of questions about just how seriously one should take superstitions. There aren’t that many superstitions that I have ever taken that seriously, and certainly the least of them would be 666 being the “number of the beast”. Friday the 13th has only been a truly bad day for me once out of the 72 times it has come up on the calendar since I was born (and most would say it was my own damn fault, but I won’t get into that here). When I travel, I don’t fly (the last time I got on a plane was about 10 years ago and the security procedures have gotten ridiculous), and I think Greyhound schedule numbers all have four digits (though whether they intentionally avoid any ending in or containing 666 is up for debate). Even then, I wouldn’t have any issues boarding a flight 666 even on Friday the 13th. (One of the few airline flights I took, if I remember correctly, was on a Friday the 13th, and I lived to tell about it.)

If only it were that simple. We don’t even know for sure if 666 is the real “number of the beast.” According to this Wikipedia article some early manuscripts have 616 for the “number of the beast” instead of 666. Would this make June 16 the unluckiest (or most devilish) day of the year? Should it have been flight 616 to HEL that we should have been keeping an eye on?

I did search for any record of any airline’s flight 666 or flight 616 crashing or having any type of incident, whether on Friday the 13th or not. So far I have not come up with anything. A Wikipedia article I consulted shows four flights ending in 13 having incidents; I did not check to see if this is within statistical norms but I suspect it is. Given the number of airline incidents over the years, it would be difficult to find all incidents that have ever occurred on a Friday the 13th, regardless of flight number. If there’s enough interest, I’m willing to dig deeper. If someone has already researched this, I’d love to know about it and do a followup post on the topic.

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’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.

Ode to Houston’s switched-off red light cameras

Just under two weeks ago, voters in the city of Houston, Texas, defeated Proposition 3 by a fairly wide margin, bringing the city’s controversial photographic enforcement of traffic signals (red light cameras) to an end. This morning, at 10am, as mentioned in a post to Swamplot and a story on KPRC’s (Channel 2) website.

And not a moment too soon. The road to hell is indeed paved with good intentions, and while the intentions of installing red light cameras may be good, the implementation and eventual result was bad. For one, any time you have money changing hands for something like red light violation fines, there’s an incentive for greed at the expense of safety. Even if the city or county governments don’t get the fines. Even if they go to local hospital trauma centers. Greed is greed.

You’ll have to just trust me on this, but months ago I once had occasion to make a trip by bus to the Willowbrook mall area, where one of the red light cameras is installed at State Highway 249 and FM 1960 (which is now named Cypress Creek Parkway in addition to its FM number, but was not at the time). I got to observe the intersection enforced by the red light camera. Most of the red light runners were not the “zoom through trying to beat the light” type that usually come to mind when someone mentions “running a red light.” No, these were people trying to sneak across on the tail end of a yellow, going by my estimation 20-25 mph (maybe even as low as 15 mph in some cases), well below the limit of 35 mph on the exit ramp/service road for FM 1960. These were not the menaces to safety that got the red light cameras up to begin with.

To make matters worse, after pacifying the angry citizens with a promise that red light cameras would not be used to issue tickets to right turn violations, the city reneged on this and quietly started ticketing them too. Why? Greed! Pure greed! My mom got one of these tickets.

The Houston red light camera era overlapped significantly with my run as a courier/messenger in the Houston area; thankfully, I never got a ticket from one, either on or off duty. However, knowing the cameras were there and I risked a rear end collision every time I stopped on a fresh yellow light just to make sure I didn’t get a ticket did nothing to ease my already stressful life on the road.

Maybe now that the people have spoken, the city of Houston can time yellow lights properly on traffic signals, a move proven to increase safety. It won’t make the city any money, of course, but wasn’t this whole thing about safety to begin with?

It should be noted that Baytown also voted out the red light cameras in the same election. However, other cities such as Pasadena, Jersey Village, and Humble, appear to be retaining their cameras at least for the short term. It is my sincere hope that these other cities seriously consider following Houston’s lead and put the matter up for referendum in the next election. It’s time to make the entire greater Houston area safer–by getting rid of the cameras and actually focusing on safety, not money.

Now, if you’ll excuse me, I’m off to hunt down my recording of “Ding Dong The Witch Is Dead.” Good riddance, red light cameras. You won’t be missed.

This is justice? For who?

WCPO-TV in Cleveland, Ohio, reports on what can only be described as a sad case for everyone.

Eric Cropp, a pharmacist at the time of the incident, gave an overdose of saline to a two-year-old cancer patient, resulting in her death. His sentence: six months in jail, six months house arrest, and three years probation including 400 hours of community service. (The article does not mention a fine.)

It’s sad for the family, who saw their young daughter almost make it through cancer treatments, only to perish in a truly unbecoming fashion.

And it’s sad for Cropp, who is not only facing a forced career change after losing his license, but now has to deal with what will now be uncomfortable questions about criminal background when applying for other jobs.

Now, some of you out there will go on about how he only got three years probation, so he got off easy, etc. But the true sentence here is not the three years’ probation and the jail time.

Even if not actually convicted (it does not state whether he has gotten some kind of sentence that is not supposed to result in an actual conviction, such as deferred adjudication like we have in Texas), Cropp is getting what is in effect a life sentence. Even after having completed his probation it is likely that despite anything his lawyer told him, he’ll still have a record. If Ohio’s public records system is anything like the one in Texas, the average person unwilling to actually chase down the details will not even know that the record for Cropp is a “not-a-conviction-that-looks-like-one.”

The really sad part? According to a USA Today story from 2008 February, Cropp isn’t even the one that actually made the fatal mistake of substituting a 23.4% saline solution bag for a 0.9% bag. The error was actually made by Katherine Dudash, the pharmacy technician. But Cropp bears the full brunt of responsibility because he missed the error and because Ohio does not regulate pharmacy technicians.

I don’t excuse the mistakes that Cropp did make, or to say it’s okay for anyone to make the kind of mistake that results in loss of life. But neither do I excuse the unfairness towards Eric Cropp and the completely backwards laws that let Katherine Dudash get off scot free.

The only happy ending to this, is apparently Dudash also now holds a non-pharmacy job (she went back to work at CVS after the incident and changed careers some time later). But she’s not going to have to deal with having to check yes to job applications that ask “have you ever pleaded guilty or no contest to a felony?” or similar questions. That’s unfair and thoughtless towards someone who spent years training to become a pharmacist. That’s what makes me sick.