Monday, March 22, 2010

A deadly profession

By now most, if not all people in the world of pharmacy have heard the story of Eric Cropp. He's the pharmacist from Ohio who was involved in the case where a little girl received a fatal dose of sodium chloride in the chemotherapy IV. Rather than having normal saline in the bag, she received 23 percent.

The technician who prepared the IV was preoccupied with her wedding plans. On the day of the incident, the pharmacy computer system was not functioning correctly and orders were piling up.

Mr. Cropp was sentenced to six months in prison, six months house arrest, and 400 hours of community service after being convicted of involuntary manslaughter. The Ohio State Board of Pharmacy revoked his pharmacist license. In Ohio, when your license is revoked you can never practice pharmacy again. Suspension yes, revocation no.

As a result of this error, the State of Ohio has passed legislation that requires all pharmacy technicians to be certified. Another example of government being reactive rather than proactive. But in all honesty, would technician certification really have made a difference in this case? I don't know, but I want to share some thoughts.

First of all, this reminds us of the seriousness of any error that we might make. One little mistake and it could cost somebody their life. We've all made mistakes at one point or another. It's serious stuff. If you want to see laser beam focus, check out a pharmacist who was just notified about an error. It doesn't matter who made the error, patient safety is the main concern.

When it comes to IVs, the pharmacist is the last line of protection for the patient. I don't know the inner workings of inpatient pharmacies at the hospitals, but it would be difficult for me to not prepare the IVs myself. Heck, I don't even allow my techs to reconstitute antibiotics without checking the volume of distilled water that the draw up prior to adding it to the powder. And I only do that if I'm trapped on the phone and can't get to our area where we reconstitute the meds. Just as this incident with Mr. Cropp illustrates, it's my license on the line, not the technicians.

This incident also reminds us of the effects of being distracted in the pharmacy. In this case the technician had her mind on something else and wasn't the most attentive. Normally the pharmacist would catch the error, but he was distracted as well. I know what it's like when the computer system has issues. Throw in a couple calls from the floor from nurses wondering "where the damn meds are" and I'm sure Mr. Cropp was overwhelmed and just trying to please everybody.

This case also illustrates the importance of adequate staffing. For pharmacists in the retail setting, you need to stick to your guns when management comes after you to decrease your payroll budget. Can the pharmacy operate with fewer technician hours? Yes, probably. Can we do it and ensure that there we be no errors? We can never do that. We need to remind them that every distraction that the pharmacist faces, be it ringing phones, people asking where the aspirin is, etc, is a chance for an error. Ask management if they want that error to occur when you are filling a prescription for one of their family members.

We need to remember that the products we work with are called dangerous drugs for a reason. All it takes is one little mistake to be reminded how dangerous these medications are. Most of us will never make a mistake that kills a patient, but we need to remember that each and every medication that we handle has that potential. Remember Mr. Cropp, the family of the little girl, and the consequences of one mistake.


The Redheaded Pharmacist said...

This is why pharmacy is a unique business that should be treat as such. This I why modeling retail pharmacy after a fast food chain is a horrible mistake. This is why JC Penny could not handle the Eckerd acquisition back when Eckerd still existed. We are in a uniquely tough business where lives are at stake with every prescription that is filled.
If McDonalds messes up your lunch order you get pickles when you wanted extra mayo or a Diet Coke instead of a regular one. If we mess up an order at work someone could end up in the E.R. or worse! The sooner the powers that be in the retail pharamcy sector and in pharmacy in general realize this fact the better off we will all be going forward.
But in the end the pharmacist will alway be the easy scapegoat. My employer can cut hours to the bare bone and then cut again but if there is a resulting error then rarely if ever will the chain suffer any penalty. It will be the individual staff members at the pharmacy where the error occured that will suffer the brunt of the blame. And for a big chain that is no big deal because they can just bring someone else in to replace that pharmacist or technician that has been suspended by the board without ever addressing the underlying problems that actually resulted in the error in the first place. It is a shame really.

was1 said...

I worked for eckerd (for less than a year) shortly after the JCPenney/Thrift Drug mess. The district manager was constantly coming around with forms for us "store people" to sign acknowledging that we were aware of various company policies and procedures. The whole purpose of that was to cover the corporation's ass. If a pharmacist made an error or didn't document something or didn't do appropriate counselling, well, it wasn't the corporation's fault. After all, they have a policy and a signed form showing that the pharmacist was aware of it. It was the individual only who was at fault for violating company policy.
The bigger the company, the bigger they suck.

Anonymous said...

Contrast this unhelpful response from the Ohio board by the hospital administration and pharmacists and technicians did to help resolve the heparin overdose deaths in Indianapolis a few years ago. No matter that the registered pharmacist in charge takes the brunt, inevitably most mistakes are both a combination of inattentions as well as systems errors. With the heparin vial labeling, finally, the vial manufacturers DID something about a problem was bound to rook someone someday; the nearly microscopic labeling has been vastly improved. No doubt the concentrated sodium chloride vials could have been similarly labeled. My understanding of Eric's situation is that he took the brunt of the fall on the chin as if the thing was entirely his own fault in order to limit the knife-twisting in his gut, without doing enough to see what systems failures corrections could be corrected.

It was my understanding that they were attempting to compound TPN in a crowded busy hood. First of all, most IV rooms policies incorporate the adage that 'TPNs are NEVER stat' but he had so many things slowing the process and bogging things down that he was trying to hurry and get done. I think if he hadn't been under the gun so much to get out of there, he would've had time to dedicate to adequately checking a pediatric hood. I hope that in that pharmacy there are now policies and procedures about TPN compounding that allow them to be made at another less busy time of the day, and that preparation of all pediatric medications can be performed in a special dedicated area, to focus on some aspects of precedence. I also think that Eric was doing too many different kinds of things at once, sorting labels, fixing batch deliveries, taking orders, as well as checking products and overseeing the IV room. When this fracas is going on, he should've been able to call in someone to take over part of the job, e.g. entering orders, so that he could focus on the most important aspects for the pharmacist in ensuring a safe product. In this situation, if I had doubts of the capability of the tech, I'd have had them leave to somewhere else to do something else, e.g. enter orders, and I would've been the one to compound. On the other hand, it would've been hard to say what exactly I'd have done. I have been known to throw out techs whose attitude was not copacetic with workflow, or stop the madness by closing the door and working in silence with iteration of exactly each step of what was going on, to help with focus. In any case, the quick 'punishment' of Eric forestalls any positive attitude of self-correction and self-analysis, without addressing the root cause, which most likely was NOT Eric. Some things are logical; if A, then B. If A does something wrong, then he should be punished. but, it doesn't seem like that was the case. What did Eric do wrong? What was wrong, that Eric merely facilitated?

Anonymous said...

If I had the power to make changes in my payroll budget I would Eric, but sadly, they send down the hours I get each period and say "here, this is what you get based on OUR projections" If you go over your ass is grass". Well, the last part is mine, but you get the gist of it. They run a skeleton crew every day based on some "model" of their own ivention. Their model says that 1 pharmacist and 1 tech should be able to complete 250 rx in one day. yea, maybe if no phones rang, and nobody asked any questions and no one came to the cash register. Their own workflow model was designed for 4-5 people. now we get 2. you know me pretty well but today I am anon..