Eric Cropp weighs in on the error that sent him to prison

Eric Cropp weighs in on the error that sent him to prison
From the December 3, 2009 issue

In 1997, ISMP announced its first annual list of CHEERS recipients comprising individuals, groups, and companies that set a superlative standard of excellence for medication safety during that year. This list was the precursor to our annual ISMP Cheers Awards, which we began presenting at a gala dinner celebration in 1998. Those who have followed ISMP for many years may remember that, originally, our list of CHEERS was accompanied by a list of JEERS for those that had impudently frustrated patient safety efforts during the same year. However, after 2 years of compiling an annual list of CHEERS and JEERS recipients, ISMP abandoned the practice of “jeering” individuals, groups, or companies in a desire to lead the way for a much-needed change in the punitive culture of healthcare.

Our 10-year ban on JEERS was sorely tested after two ISMP staff entered the Cuyahoga County prison to visit Eric Cropp—an Ohio pharmacist serving a 6-month jail sentence for failing to detect a technician’s chemotherapy mixing error, which resulted in the death of a 2-year-old child, Emily Jerry. Before the visit, ISMP had written about the particularly harsh, unjust, uninformed, and unprecedented treatment of Eric Cropp by the Ohio State Board of Pharmacy and the Cuyahoga County criminal justice system.(1,2) ISMP stands by its commitment to avoid publicly “jeering” any individual, group, or organization, particularly in this case, since we have not had an opportunity to personally converse with representatives with the Ohio Board of Pharmacy and the criminal justice system. However, by the end of the prison visit, ISMP felt compelled to share some of our experiences from the visit and Eric’s thoughts about the error in order to offer our readers a more balanced portrayal of our imprisoned colleague.

The prison visit was powerfully tragic, maddening, and unsettling:

Powerfully tragic to see a fellow healthcare practitioner, who loved being a pharmacist, so out of place in an orange jumpsuit behind an impenetrable glass wall with only phones on both sides for communication, tentatively standing among other prisoners convicted of violent crimes
Maddening to glimpse the emotional and physical toll imprisonment is having on Eric and to view firsthand how the Ohio State Board of Pharmacy and the Cuyahoga County criminal justice system have all but destroyed this man’s life and livelihood without just cause
Unsettling and cautionary to realize that any other healthcare practitioner who has made a serious medical error could easily be in Eric’s position because we are all susceptible to human error, and we all occasionally drift into rushed practice habits when forced upon us by systems and conditions that seem to demand it.
During the prison visit, Eric told ISMP staff more about himself, how the error occurred, and about his experiences with the Ohio State Board of Pharmacy, the criminal justice system, and his prison term. Eric had about 8 years experience with IV admixtures and had been working with chemotherapy admixtures at the hospital where the error occurred for about 2 years. With a BS in Pharmacy, he had been attending class to earn a PharmD degree, and he had previously served as President of the Northern Ohio Academy of Pharmacy.

The error happened on a Sunday morning, with typical weekend staffing. Eric was busy and had taken no breaks and had not eaten any meals during his shift. Routine maintenance had been performed on the computer the night before, and the pharmacy system was not available until mid-morning. The labels for IV admixtures, which typically printed around 7 a.m., printed later that morning, causing a delay in preparing solutions. Eric received a call to dispense Emily’s chemotherapy right away, although it was not needed until hours later (unknown by Eric at the time). After the technician mixed the solution, he felt rushed to check the chemotherapy, which was among many other solutions, vials, and syringes in a very small, crowded checking area. Eric saw an empty 250 mL bag of 0.9% sodium chloride near the bag of chemotherapy and assumed the technician had used it to prepare the base solution.
Eric states that the technician later testified that she had told him something seemed “weird” about the solution. Eric does not recall this conversation. He only recalls asking the technician whether she had used sodium chloride, which she answered affirmatively. Eric also saw a vial of 23.4% sodium chloride on the crowded table and assumed the technician had used this vial to prepare the prior chemotherapy order, which required the use of an automated compounder. The chemotherapy Eric was checking had been prepared by an experienced technician, but instead of premixed 0.9% sodium chloride, she had used three vials of 23.4% sodium chloride. Eric failed to detect the error and dispensed the solution. In this case, the confluence of system and human errors led to tragedy.

Representatives from the hospital where the error occurred were cooperative with ISMP and shared some details of the error. Although a few conditions described by Eric are disputed by the hospital, there is general agreement in many areas, as evidenced by the subsequent system changes that the hospital has employed to improve medication safety since the event.
Upon learning about the error, the Ohio Board of Pharmacy investigated the event and scheduled a hearing with Eric. The system allowed the Board to serve as “judge and jury” regarding possible revocation of Eric’s license, without the ability to appeal the decision. Incomprehensibly, the Board investigators determined that no system issues or adverse performance shaping factors played a role in the error. Eric had never made any serious errors before this event. However, the Board investigators identified a series of 14 errors that Eric made after the event at a new place of employment, a community pharmacy. According to Eric, some of these errors did not reach patients and were documented for training purposes only to help him learn the quirks of a new pharmacy computer program. Of the two errors that Eric remembers reaching patients, one involved a mix-up between 50 and 100 mg tablets of sertraline, which the patient returned before use, commenting that it had happened several times before when other pharmacists had filled her prescription. The other error involved accidentally changing the directions on a prescription for COMPAZINE (prochlorperazine) from “for nausea and vomiting,” as prescribed, to “for pain.”

Several witnesses testified on Eric’s behalf, but the Board found them unpersuasive. Much of the hearing was devoted to the emotional testimony of Emily’s family. At the time, Eric was still suffering from what he describes as post-traumatic stress, for which he has not yet received treatment; listening to the parents’ testimony was agonizing and he felt frightened, depressed, intimidated, overwhelmed, and defeated by the end of the day. He had heard witnesses calling him a murderer, and he acknowledged that his demeanor throughout the hearing was distraught and agitated at some points and flat at other times. At the conclusion of the hearing, it is understandable that Eric was emotionally wrought and told the Board he was unable to practice pharmacy. Citing that he was guilty of misbranding a dispensed product because he had signed the label on the chemotherapy which stated the base solution was 0.9% sodium chloride, the Board voted (Aye-6, Nay-2) to permanently revoke Eric’s license (http://pharmacy.ohio.gov/minutes/mins07040911.pdf), never giving him a chance to heal and show he could become a reliable, competent pharmacist again—an even better pharmacist, having gone through this experience.

After the Board’s decision, a Cuyahoga County district attorney decided the case merited criminal prosecution. Eric was charged with reckless homicide and manslaughter. Under the manslaughter charge, strict liability associated with misbranding the product was alleged. The difficulty with defending the misbranding allegations, along with fear of even harsher penalties, led Eric to plead guilty to a lesser count of involuntary manslaughter. He was sentenced to 6 months imprisonment, 6 months of home confinement, 3 years of probation, 400 hours of community service, and a $5,000 fine. Eric’s attorneys believe the judge was influenced by the passionate testimony of Emily’s mother, who pleaded with the judge to sentence Eric to the maximum penalty—5 years imprisonment.

Both the Ohio State Board of Pharmacy and the Cuyahoga County criminal prosecution have made an egregious error pursuing, charging, and sentencing Eric for what was—without a doubt—a mistake; a mistake with tragic consequences, but a mistake nevertheless. The Board failed to conduct a thorough, credible, and expert investigation upon which to base its permanent revocation of Eric’s license. Many dispensing errors bear an element of misbranding if the product is not what is listed on the label. Thankfully, the Board has not similarly punished all pharmacists who have made dispensing errors on these grounds. However, we have heard from Ohio pharmacists who have experienced unjust treatment at the hands of the Board. Not surprising, some have told us they are afraid to speak up against the Board—and we certainly don’t blame them!

The criminal system should have absolutely no role in dealing with medical errors unless it involves intentional harm or willful and recurrent violation of safety rules not caused by institutional failures, if harm was foreseeable.(3) While Emily’s death is a terrible tragedy, Eric’s case met neither of these criteria, and he is by no means a criminal. As stated by Wachter and Shojania in the book, Internal Bleeding,(4) “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,(5) ‘It is essential that the law should do so.’ ”

On November 20, 2009, ISMP and CareFusion sponsored a 2-hour webinar to review the compounding error that happened in this case, identify common practices and system issues that can lead to compounding errors, and suggest prevention strategies. Faculty for the webinar included ISMP staff, Bona Benjamin from ASHP, Robert Wachter from the University of California, and Eric’s attorneys. The primary purpose of the webinar was to help organizations reduce the risk of parenteral compounding errors, but we also wanted Eric to have a voice, through ISMP, to provide insight into the “second victim” of an error—the practitioner who makes a fatal error. We encourage everyone to listen to the freely available webinar at: www.carefusion.com/center/conferences/Webcasts.aspx. The webinar also showcases the important lessons learned that Eric asked us to share with other healthcare practitioners, and potential future implications of criminal charges on transparency, accountability, and just culture. Dr. Wachter has added his views about Eric’s case to his blog, which can be viewed at: www.wachtersworld.org.

ISMP is making tentative plans to host Eric at the end of his imprisonment (February 14, 2010) and home confinement, to help him complete a portion of his community service hours. If you would like to provide words of support to Eric, please send mail to the following address: Eric Cropp (S.O. 266577), Cuyahoga County Jail – Pod 7G, P.O. Box 5600, Cleveland, OH 44101. When we asked Eric if there was anything in particular we could send him while he is imprisoned, he asked for newsletters and pharmacy journals to help him stay abreast of the pharmacy profession he still loves.

Our support for Eric in no way lessens our condolences to Emily’s family or minimizes the pain her family will forever bear from losing a child due to a medical error. Our hearts and prayers go out to Emily’s family as well as to Eric and his family.

References
1) ISMP. Ohio government plays Whack-a-Mole with pharmacist. ISMP Medication Safety Alert! August 27, 2009.
2) Cohen MR. An injustice has been done: jail time for an error. Patient Saf and Qual; September/October 2009:6-7.
3) Wachter RW. Jail time for medical error, redux: the case of Eric Cropp. Wachter’s World. Nov. 26, 2009. Accessed on November 28, 2009, at: www.wachtersworld.org
4) Wachtner RE, Shojania K. Internal Bleeding: The Truth Behind America’s Epidemic of Medical Mistakes. NY: Rugged Land, LLC, 2004.
5) Merry A, McCall Smith A. Errors, Medicine and the Law. NY: Cambridge University Press, 2001.

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Eric Cropp weighs in on the error that sent him to prison