WCPO-TV in Cleveland, Ohio, reports on what can only be described as a sad case for everyone.
Eric Cropp, a pharmacist at the time of the incident, gave an overdose of saline to a two-year-old cancer patient, resulting in her death. His sentence: six months in jail, six months house arrest, and three years probation including 400 hours of community service. (The article does not mention a fine.)
It’s sad for the family, who saw their young daughter almost make it through cancer treatments, only to perish in a truly unbecoming fashion.
And it’s sad for Cropp, who is not only facing a forced career change after losing his license, but now has to deal with what will now be uncomfortable questions about criminal background when applying for other jobs.
Now, some of you out there will go on about how he only got three years probation, so he got off easy, etc. But the true sentence here is not the three years’ probation and the jail time.
Even if not actually convicted (it does not state whether he has gotten some kind of sentence that is not supposed to result in an actual conviction, such as deferred adjudication like we have in Texas), Cropp is getting what is in effect a life sentence. Even after having completed his probation it is likely that despite anything his lawyer told him, he’ll still have a record. If Ohio’s public records system is anything like the one in Texas, the average person unwilling to actually chase down the details will not even know that the record for Cropp is a “not-a-conviction-that-looks-like-one.”
The really sad part? According to a USA Today story from 2008 February, Cropp isn’t even the one that actually made the fatal mistake of substituting a 23.4% saline solution bag for a 0.9% bag. The error was actually made by Katherine Dudash, the pharmacy technician. But Cropp bears the full brunt of responsibility because he missed the error and because Ohio does not regulate pharmacy technicians.
I don’t excuse the mistakes that Cropp did make, or to say it’s okay for anyone to make the kind of mistake that results in loss of life. But neither do I excuse the unfairness towards Eric Cropp and the completely backwards laws that let Katherine Dudash get off scot free.
The only happy ending to this, is apparently Dudash also now holds a non-pharmacy job (she went back to work at CVS after the incident and changed careers some time later). But she’s not going to have to deal with having to check yes to job applications that ask “have you ever pleaded guilty or no contest to a felony?” or similar questions. That’s unfair and thoughtless towards someone who spent years training to become a pharmacist. That’s what makes me sick.
This shows you what kind of profession pharmacy has become. If Mr. Cropp was a physician, what would likely have happened?- a slap in the wrist and a small fine. Pharmacists do not stick together, never have, and but for the grace of God this could have happened to most of us. Not withstanding the terrible events, he made an error of judgement brought out by the fact that pharmacists are overworked and delegate to much to technicians. Unfortunately for the future, more technicians and fewer pharmacists will be the norm,and mistakes like this will be more likely to happen. Are pharmacists really that "lucky" Look at the real world and what is happening for a change!
Thanks for the unique insight.
For the record, this is the first time I have ever commented on a pharmacy-related story. I was commenting more from the perspective of "justice run amok" than "pharmacists are getting screwed." Not to say I disagree with the latter perspective at all, of course.
Are there more cases like this involving the pharmacy profession that need light shined upon them?
Fortunately 'Katherine Dudash' is a pretty unique name. From Ohio. Google is our friend, hopefully anyone going to hire her will check her name out and stuff like this will come to the top. What goes around comes around, Kate.
Katie Dudash should have been the first one punished regardless of whether or not she was just a tech or not. Yes, her supervisor she also be punished; however, if Katie is not punished, she will go on to make the same mistakes in her career. Trust me, I've seen in happen in other medical professions where patients have died due to careless mistakes of physicians, nurses, lab techs, radiology techs, etc. I'm terminally ill because of many medical mistakes gone punished. The same physicians keep making the same mistakes over and over again because they are never held accountable for their negligence and carelessness. Lab results are missed or ignored or forgotten until it is too late. I had a urine cytology with a positive diagnosis of a urothelial carcinoma in 2006; however, several Mayo Clinic physicians missed the lab result. In 2009, I had been on narcontic pain medication for three years for renal pain, blood in my urine, renal failure, unexpected weightloss of 50 lbs in three months. I begged my doctor to find out what was wrong with me. By that timei was too late for treatment, it had metastasized to several locations away from my kidneys. Punishment does help teach them to pay attention to what they are doing.
Yes it is sad for pharmacists to be punished for technician errors. However, often the technician had their licence revoked if there is enough of a reason to In the case of Emily Jerry, the one at fault was essentially the pharmacist because he was not supervision her which is his legal obligation. He allowed her to compound a solution when there was no real reason to. He has the final say before the medication left and he let it go. On top of this, he was charged not because of this incident. He was charged because other pharmacy errors that lead back to him and that is why he served jail time and got his licence revoked. He was charged for being a crappy pharmacist, and at the end of the day yes she made a mistake but it was under his care and he authorized it. He had a history of errors. So don’t make it seem like he’s this innocent victim in this case.
I learned a few things since I originally made this post. The order for the saline solution came in early in the day, leaving Eric and his tech to believe they needed it immediately. However, they didn’t need it until later that afternoon. In a lot of pharmacy environments like the one Eric worked in, shifts are long and breaks are both short and rare. It is this that needs to be fixed to keep these kind of things from happening.
Again, I’m acknowledging that Eric screwed up, and it’s likely he deserved a temporary suspension of his license for the cumulative effect of this and other errors. I simply don’t think criminally prosecuting Eric solved any particular problem. If anything, I think it leaves potential new pharmacists leery of entering the profession (see my later posts).
Also, if memory serves me correctly, when this originally happened Ohio either did not license it’s pharmacy technicians or the licensing process was much less stringent. This has of course changed since.
My understanding is Katherine Dudash is no longer a pharmacy technician as of shortly after this incident. And, Ohio now licenses their pharmacy technicians (they did not at the time of the incident).
This is not a technician error. Know your facts.
Really? Who originally mixed the solution?
I’m not saying the technician made all the mistakes here, but she made the one that really mattered. There were other contributing factors as well (I have studied this case more deeply than you might think).