One commenter provided additional detail about the system problems that prevailed:
...it was a Sunday morning and the HIT devices were experiencing “unplanned downtime”. Directly from the ISMP report:
“The pharmacy computer system was down in the morning, leading to a backlog of physician orders.
The pharmacy was short-staffed on the day of the event
Pharmacy workload did not allow for normal work or meal breaks.
The pharmacy technician assigned to the IV area was planning her wedding on the day of the event and, thus, highly distracted
A nurse called the pharmacy to request the chemotherapy early, so Eric felt rushed to check the solution so it could be dispensed (although, in reality, the chemotherapy was not needed for several hours).”
The commenter went on to question whether down time procedures had been developed or were carried out. In the body of his post Bob mentioned that an empty .9% saline bag on the counter near the chemo mixture suggested that indeed it had been used for the preparation. That raises another question. Was the chemo mixture that was actually delivered labeled as 23% sodium chloride? If so, how many other people, including the patient's nurse, handled the infusion bag? Did they notice? Should they have? If it was not so labeled how (particularly with the computers down) was Cropp to know?
And why the rush to administer the chemotherapy? Was there bed control pressure? Would a time out have helped? Would this have happened back in the pre-HIT days? (Likely not).
Another reader commented on the culture of blame:
Eric’s imprisonment is a tragic demonstration of how early we are in this patient safety journey in the culture/systems of our healthcare organizations, in our understanding of accountability, in medical liability and the courts, and in public policy. Yet I am most worried that we will all fail to learn from this case, fail to ask the question “Could it happen here?” and be writing in a short time about another dead child, another devastated family, and another nurse, doctor, or pharmacist.. Instead of imposing the scarlet letter of accountability on this jailed pharmacist, will we do something about the fact that “Our systems are too complex for merely extraordinary people to perform perfectly 100% of the time?”
Not just yet, apparently.
4 comments:
I am a pharmacist in central Arkansas. It gave me chills to read the account of Eric Cropp. I have been in the same situation as he MULTIPLE times. It never fails, it is always a weekend, or holiday, you have a relief physician unaccustomed to your institution wanting something you don't have, as well as, having technicians "winging it" in an area that they don't usually work in. Phones are ringing, people are talking, you are pressured to do something out of your routine and there is a giant pile of medications that you have to "check" for accuracy. You do the best you can, try to give your "good techs" the benefit of the doubt, and balance speed and accuracy to make the most efficient system with what you have. My point is, this could have been me on multiple occasions, and I speak for many pharmacists who trembled as they read about Mr. Cropp. We have ALL been in his situation. It is a tragedy on so many levels. This is the definition of cruel and inhumane punishment that our justice system is supposed to protect against. I hope some high level attorney brings suit against Ohio and Mr. Cropp never has to work again. Where is the hospital's liability amongst this?
I am a retail pharmacist in New Jersey and have made my share of mistakes always to realize them later and follow-up immediately on them. This is almost always due to over-burden. So it just saddens me that an over-worked pharmacist made such a grave mistake unintentionally and is now paying so dearly for it that he has lost a means of livelihood. The law should understand that pharmacists are over-worked and instead of punishing one pharmacist for it, should ensure that all pharmacies have adequate help to sustain the pharmacy. I hope for the best for pharmacist throughout the States and for the profession of pharmacy.
As a pharmacist, I realize that there, but for the grace of God, go I. Pharmacists have allowed themselves to be overworked and delegate so much of their responsiblities to technicians w limited training(to put it mildly) If a physician were responsible for this tragic error, he would get a slap on the wrist and a fine. Pharmacists should understand that their professions is weak and will not stand up for them if a tragic error occurs. And this is more likely to happen as the job market erodes and pharmacists will become a dime a dozen--and mark my words, it will happen thanks to the greedy pharmacy schools and their desire to crank out as many graduates as possible for roles that have not been and probably never be realized.
I feel this is representative of a common sickness in our culture. We are all about patchwork "fixes" for the symptoms of our problems, and have zero desire to reach the root causes and attempt to address them. See school gun violence (let's just ban guns everywhere!), airborne terrorism (let's force everyone thru naked full body scanners!), drunk driving deaths (let's put up random checkpoints that horribly violate the 4th Amendment!), the Georgian luger's death in Candada (it's his fault he was out of control, the poor design of the track is not at all at fault!). It makes me worry for the fate of our country.
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