Here's one to ponder and comment on – does putting a pharmacist in jail for six months and ruining his career and life do anything to bring back a two year-old girl? Does it do anything to make future patients any safer? Watch this video from CNN about Eric Cropp, an Ohio pharmacist who was convicted and put in jail for six months after a fatal process error…
For those who can't see the video, there's a transcript of the story here (scroll down or search the page for Cropp).
From the story:
In 2006, Eric Cropp was a pharmacist at a Cleveland hospital when 2-year-old cancer patient Emily Jerry was killed by the medical error of a pharmacy technician. She was given a chemotherapy drug mixed with a salt solution 23 times more concentrated than the normal dose. But because Eric Cropp was the supervising pharmacist and should have caught the mistake, he was sent to jail. And that's where I found him, confused, and struggling with regret.
My sense of outrage is overwhelmed by my sense of sadness over this whole case, between the tragic death of the little girl, Emily Jerry (more about the case and the girl), and about how the reaction does nothing to make other patients safer. I've started to blog about this a few times and I've kept putting it aside… even if I can't muster the full energy that this deserves, I'll put the video and the link out there, you can comment.
I don't think I have to belabor the point for Lean thinkers. I agree with the quoted patient safety experts who say that punishment like this will do nothing but force future problems underground. People would rather cover up problems than risk jail… that's not good for anyone. That doesn't bring back the little girl.
MATTINGLY: Cropp says the mistake that killed Emily Jerry came on a day when he was overloaded and rushed. These are common complaints throughout the nation's medical system. Patient safety advocates warn that cases like this might actually make it harder to change the conditions where tragic errors are made.
MICHAEL COHEN, INSTITUTE FOR SAFE MEDICAL PRACTICE: People are going to be afraid to come forward and identify problems that they've been involved with. Because of fear for losing their license, or, you know, in this case, even have criminal charges brought against you.
MATTINGLY: Michael Cohen for the Institution of Safe Medication Practices was among the advocates calling Cropp an easy target, saying the greater good is served by focusing on system issues that allow tragedies like this to happen. But in the court's eyes, Cropp had no excuse for missing the mistake that killed Emily Jerry. He's serving six months for involuntary manslaughter.
It *feels* good, maybe, to put a guy in jail… to hold him accountable, possibly to make an example of him. Cropp claims he was overworked and the pharmacy was chronically understaffed. Has a CEO or other hospital leader ever been convicted for systemic problems in a hospital? Whose fault is it if the pharmacy is overworked? Who goes to jail for that?
You might also remember this case I blogged about, in 2006, where an error a Wisconsin nurse was involved in was criminalized. Again, does that really help?
UPDATE: Please listen to my podcasts with Chris Jerry, the father of Emily Jerry:
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