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.