August 20, 2009 | Mark Paradies

Pharmacist Gets Six Months in Prison for Fatal Prescription Error

I don’t believe in criminalizing errors and putting people in jail for honest mistakes.

Here’s one where the supervisor (a pharmacist – Eric Cropp) pleaded guilty to involuntary manslaughter and received a six-month sentence, plus six months house arrest, three years probation, 400 hours of community service, plus a $5,000 fine after a technician made a mistake in mixing a chemotherapy prescription (ended up with 23% saline rather than 1%) and killed a two-year-old.

Here’s a quote from a USA Today article about the mistake:

“Dudash, in her statement, wrote that she told Cropp, “This doesn’t seem right,” after preparing the intravenous solution for Emily’s chemotherapy. Cropp “shrugged it off,” she wrote. Joann Predina, a pharmacy board investigator, found Dudash had spent time on the Internet “planning her wedding” during a lull before the error.

In his notarized statement to the board, Cropp wrote that he had been rushed, “which caused me to miss any flags that Katie had done something wrong.”

Unlike Cropp, Dudash has not faced disciplinary action or prosecution. In part, that’s because Ohio is among at least 11 states that do not regulate pharmacy technicians. In Ohio, “The technician has no legal responsibility. It all falls back on the shoulders of the pharmacist,” says Tim Benedict, assistant director of the state’s pharmacy board.

After the fatality, Dudash returned to the CVS (CVS) drugstore chain, where she had worked and passed a technician training program before landing the hospital job. CVS spokesman Michael DeAngelis says she now holds a non-pharmacy job and would not grant interviews.”

Here’s another story about the sentinel event that was published in the Cleveland Plain Dealer:

The comments are especially interesting. (One calls for the death penalty while others argue the facts of the case).

It’s hard to tell what the facts were from this news coverage. And, of course, everyone sympathizes with the family that lost their daughter.

What are the required protocols?

How could a mistake like this be made?

Why didn’t the technician use a pre-mixed solution rather than mixing one from scratch?

There seem to be a lot of unanswered questions … maybe they have been answered and just didn’t make it into the press coverage?

But from what I can read here … It’s hard for me to see how a jail sentence for a supervising pharmacist will make the system safer.

A thorough root cause analysis seems like a much better action.

Patient Safety & Healthcare
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