RPh second victim in Ohio drug error

January 15, 2010

A webinar examining the pharmacy error that led to the death of a two-year-old girl and the conviction of an Ohio pharmacist criticized the legal system for criminalizing the event as well as the flawed hospital procedures that prevented discovery of the pharmacy tech's fatal error.

Key Points

Eric Cropp was a victim of his own pharmacy error.

The former supervising pharmacist 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 technician 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 clinician involved has become a second victim."

"I am disappointed with my colleagues in Ohio and their silence in this case," Cohen said, in response to a question. "I expected better of my fellow pharmacists, I expected better of the judge, and I expected better of the Board of Pharmacy who, Eric Cropp's attorney has said, acted like a kangaroo court.

"The Board found no system errors on the part of the hospital, which was clearly wrong," Cohen continued. "The hospital pharmacy made significant changes to their processes and physical facilities since this error occurred. This was purely a tragic accident, 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. IV preparation protocols were incomplete and not strictly enforced, and hypertonic sodium chloride was within easy reach. ISMP has long called for hypertonic solutions to be kept under lock and key or in a separate, hard-to-access area to guard against accidental substitutions with normal tonic solutions.

In this case, the technician prepared the chemotherapy dose using 23.4 percent saline instead of 0.9 percent saline. An empty saline bag next to the finished chemotherapy preparation suggested that the dose had been prepared using the proper base solution.

In testimony to the state pharmacy board, the patient's mother, Kelly Jerry, said her daughter woke up after treatment groggy, thirsty, and with a terrible headache before falling into a coma. The girl died from hypernatremia.

"Eric Cropps's incompetence goes far beyond conducting one reckless act," Jerry said in prepared testimony to the Board of Pharmacy. "Eric Cropp consciously disregarded any and every set standard of protocol regarding patient safety. How many more people does Eric Cropp have to kill before his license is revoked? Isn't our daughter Emily's death one too many?"

The Board permanently revoked Cropp's pharmacy license in 2007. He was also charged with reckless homicide and involuntary manslaughter. The reckless homicide charge was dropped when Cropp agreed to plead no contest to involuntary manslaughter.

There was little alternative to the plea bargain, said Cleveland attorney Richard Lillie, who represented Cropp. Ohio law uses strict liability to define involuntary manslaughter, which left Cropp with no defense. He was sentenced to six months in jail, six months of home confinement, a $5,000 fine, and court costs.

"I believe fully that what has happened in this case is wrong," said medical safety expert Robert Wachter, MD, professor and chief of medicine at the University of California, San Francisco. "The criminal system has no place in dealing with professional mistakes. Even Emily's dad, Chris Jerry, said, 'I know it was a mistake.' The criminal justice system might have a rare role in egregious, reckless behavior, but accountability for professional mistakes should be at the professional level."

Cohen said that Cropp wants to work with ISMP to help prevent similar errors in other institutions.