Eric Cropp: a second victim

Lately, hospitalist leader and patient safety expert Bob Wachter has been making the case for more individual accountability in the the field. But in his Thanksgiving Day post he reminds us that some medical errors, even tragic errors, are indeed system problems.

On February 26, 2006, 2-year-old Emily Jerry died because her chemotherapy was mistakenly mixed with 23% saline rather than normal saline. Eric Cropp, the hospital pharmacist who signed off on the mixture, was the second victim. Despite the fact that a root cause analysis found this to be a case of ordinary human error compounded by system problems the legal system, driven by family outcry, was bound and determined not only to have its pound of flesh but to single out one individual---Eric Cropp.

In addition to suffering criminal penalties (which Emily's mom evidently thought were too lenient) Cropp lost his livelihood. According to one news report Cropp, unable to find steady employment, worked odd jobs cleaning boats and walking dogs.

Wachter sees this as an example of objective analysis trumped by emotions and concludes:

Similarly, it is natural for the parent, spouse or friend of a loved one who dies of a medical mistake to demand a pound of flesh, damn the Swiss cheese. In Internal Bleeding, Kaveh Shojania and I wrote about this, citing the wonderful book on medical malpractice by anesthesiologist Alan Merry and famed novelist Alexander McCall-Smith (yes, that McCall-Smith). The words ring true as we think about the case of Eric Cropp:

“It is to be expected that families or patients will blame the party holding the smoking gun, just as they would a driver who struck their child who ran into the street to get a ball. Some bereaved families… will ultimately move on to a deeper understanding that no one is to blame – that the tragedy is just that. But whether they do or not, write Merry and Smith, ‘It is essential that the law should do so.’”

In this case, the law did not do so. So, as your enjoying your turkey on this day of thanksgiving, please give a thought to the victims of this terrible tragedy, Emily Jerry and her parents.

And Eric Cropp.