COMMUNITY PRACTICE

Ohio R.Ph. indicted in Rx error death

In a case that has raised red flags for healthcare professionals, an Ohio pharmacist was indicted by a grand jury last month for allegedly dispensing an overdose of chemotherapy drugs that led to the death of a cancer patient.

Daniel Scott, 41, a longtime pharmacist at Riverside Mercy Hospital in Toledo, was charged with one count of involuntary manslaughter in the death of Lyle Ganske on July 11, 2000. A tentative trial date has been set for Dec. 4. If convicted, he could face one to five years in prison.

Prosecutors charged that Scott quadrupled the dosages of Adriamycin (doxorubicin HCl, Pharmacia) and vincristine he dispensed at the Riverside Mercy Home Pharmacy Services outpatient facility. The chemotherapy drugs were to be administered via an infusion pump. John Weglian, chief of the special units division of the Lucas County prosecutor's office, said he couldn't discuss why a criminal indictment was sought, but he admitted that the victim's daughter had made prosecutors aware of the dispensing error last year.

The chemotherapy error was triggered when a nurse rewrote the physician's original order, said James Brazeau, an attorney who represented Scott before the pharmacy board. He said that the physician's order called for only one dose spread out over four days, but, in a phone call, a nurse indicated that the dose was to be "times four days," Brazeau said. The R.Ph. interpreted that to mean a dose for each of four days.

"The documentation faxed to the pharmacy included the original order and the nurse's order in the physician order section of the form," Brazeau said. "If you didn't look in the right place, you might not know there were two orders that turned out to be for two different things. The ultimate responsibility rests with the pharmacist, but here was an error that can happen to anyone who is not alert."

The Ohio pharmacy board levied the maximum fine allowed—$1,500—against Scott for the medication error at its August meeting, said executive director William Winsley. Although the victim's family sought additional disciplinary action, the board did not suspend or revoke his license. The board fined a second R.Ph. $500 for failure to properly review the script.

"There are errors due to systems and errors due to individual incompetence," said Winsley. "There were some system errors in this case, and the system has been revised. But the bottom line is the pharmacist really made some serious errors in judgment. Testimony showed the order transcribed by the nurse was not clear but was used even though the physician's order was available but was never looked at. Also, the pharmacist failed to use a proper reference to check the dosage. The idea that there should never be anything punitive when an error occurs is ridiculous."

The prosecutor did not seek criminal charges against the nurse because she didn't fill the prescription, even though the "way she interpreted the prescription was probably incorrect," Weglian said. No criminal charge was considered against the second R.Ph. because "she reviewed the prescription two days later, but, according to our experts, it would not have made any difference."

The fatal overdose should have been civil negligence, not a criminal matter, contended Jerome Phillips, the attorney representing Scott in the criminal case. He said the hospital settled a civil suit last year for about $1.2 million. His client remains on the job at Riverside Mercy, where he has been employed for 18 years. He added, "He has an excellent record and is well respected. This is an inappropriate case and a very bad situation for medical professionals."

The Scott case has area pharmacists "upset and kind of outraged," said James Garnecki, R.Ph., J.D., a hospital pharmacist who teaches pharmacy law at the University of Toledo College of Pharmacy. "What we're most worried about is setting a dangerous precedent," he said.

The medical profession doesn't need to worry about the Scott case setting a precedent, said prosecutor Weglian, who could not recall any previous Ohio criminal cases stemming from an Rx error. "The primary basis for presenting the case to the grand jury related to the enormity of the pharmacist's error," he added.

The Scott case's take-home message is that R.Ph.s should know their own limitations, said Winsley, who added, "If you don't know what you're doing, consult an appropriate reference before you act."

Carol Ukens

Carol Ukens. Ohio R.Ph. indicted in Rx error death.

Drug Topics

2001;22:22.