Former pharmacist indicted for manslaughter after med error

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."

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.

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. All three suggested that the revocation of Cropp's license by the Ohio pharmacy board might make pharmacists less willing to report medication errors if it might result in losing their license. "Right now, it would be very difficult to report even minor errors, not only because of the criminal indictment but also because of the board's action," Boyd predicted.

"Boards are always in a tough position; it is a hard call for them," Cohen agreed. "They are there to protect public health, but they have to act in consideration of the pharmacist as well. There should be a whole process to decide whether punitive action is necessary."

New legislation

Another outcome of Jerry's death has been renewed calls for higher standards for pharmacy technicians. Earlier this year before the case came to light, William Winsley, R.Ph., executive director of the Ohio pharmacy board, told Drug Topics, "We do not want to license technicians. The way we handle this is the best way-keeping pharmacists in charge of the final product." Now, legislators in Ohio have proposed "Emily's Law," which would require tech certification and add educational requirements for pharmacy technicians. According to Boyd, OPA supports the bill and has worked with its sponsor.

State regulations vary tremendously with respect to technicians. Currently, only seven states license technicians (Oregon will do so in 2008), 31 states have registration, and five states certify techs. Twenty states have no educational requirements (training, continuing education, or certification exam) for technicians.

Some pharmacy groups are beginning to push for greater standardization of technician training. ASHP has developed a model curriculum for pharmacy technician training program accreditation as the first effort to develop a national standard. In addition, the National Pharmacy Technician Association, the Institute for the Certification of Pharmacy Technicians, and the Pharmacy Technician Certification Board have all worked to develop technician training standards.