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Time to Review Dispensing Error Processes?

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	Neil Johnston articles by this author...
Introducing current ideas, perspectives and issues, to the profession of pharmacy

A major dispensing error has been reported in the US and we think it is an issue that is worth covering in our Pharmedia section, which is designed to focus opinion and perspective on a specific issue.
Earlier this year we reported on a locum pharmacist in the UK (Elizabeth Lee), sentenced to a three-month jail term, suspended for 18 months.
Go to http://www.i2p.com.au/article/ordeal-uk-pharmacist-ends
She was working at a Tesco pharmacy, that mistakenly issued propranolol instead of prednisolone for a 72-year-old patient, who died three days later in hospital.
The court heard that Mrs Lee was working 10-hour shifts without a break when the wrong drug was issued.
Elizabeth did not dispense the drug, nor was it determined who did, but being the pharmacist in charge, Elizabeth bore the full force of the law.
The judge said Mrs Lee bore “no factual or legal responsibility for the patient's death”, which a pathologist had determined was due to the patient's underlying long-term illness.
Mrs Lee voluntarily undertook not to practice her profession again and there was widespread sympathy and support for her circumstances.
The general opinion was that pharmacist errors should be decriminalised in the UK.

In the case of Eric Crop, pressure was generated because of a workplace computer breakdown and a backlog of prescriptions subsequently occurring.
Pressure created a loss of focus that further involved a miscalculation of the quantity of one ingredient that was given in overdose.
A very young cancer patient died.

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Former pharmacist Eric Cropp gets 6 months in jail in Emily Jerry's death from wrong chemotherapy solution: Toddler died from wrong chemo solution

Saturday, August 15, 2009
Leila Atassi, Plain Dealer Reporter

Source: The Plain Dealer

http://www.cleveland.com/news/plaindealer/index.ssf?/base/cuyahoga/1250325193310800.xml&coll=2

"Two-year-old Emily Jerry was supposed to leave the hospital with her family, cancer-free after her last dose of chemotherapy in February 2006.

But her little body was delivered to the morgue instead -- killed by a lethal dose of sodium chloride mistakenly mixed in her chemotherapy bag.

For that, the pharmacist who approved the solution will spend the next six months behind bars.

Eric Cropp of Bay Village was sentenced Friday for involuntary manslaughter in connection with Emily's death. His time in the County Jail will be followed by six months of house arrest and three years of probation. Cuyahoga County Common Pleas Judge Brian Corrigan also ordered Cropp to pay a $5,000 fine and complete 400 hours of community service, during which he must seek out pharmacological organizations and tell them his story, in the hopes it would prevent others from making his deadly mistake.

Cropp was the supervising pharmacist at Rainbow Babies & Children's Hospital on Feb. 26, 2006, when a pharmacy technician prepared a chemotherapy treatment for Emily.

The solution was 23 percent salt when the formula called for a saline base of 1 percent. Emily slipped into a coma after receiving the treatment and died on March 1.

As supervising pharmacist, Cropp had the duty to inspect and approve all work prepared by technicians before the drugs were administered to patients.

Cropp initially was charged with reckless homicide but agreed to plead no-contest in May to involuntary manslaughter. The State Pharmacy Board revoked his pharmacist license in April 2007.

Court records showed that a problem with the hospital's computer system on the day Emily received the deadly solution left the pharmacy with a backlog of drug orders. Records also suggested that Katherine Dudash, the technician who mixed the solution, was preoccupied with planning her upcoming wedding, the judge said...."

 

 

 

Mark Coleman

I have been asked to comment on dispensing errors and any relevant perspectives surrounding this type of issue.

When I first read the media reports above I started to feel a little uneasy, because who among dispensing pharmacists has never made an error?

With only a change of name it could well have been my name broadcast in those emotive media headlines.

My next immediate thought was who was going to represent me legally and supportively in the event of an error?

I am a member of PDL, but are they now the appropriate organisation for me, given that I am now a locum pharmacist working in differing locations in short bursts.

Although PDL independently operates in alliance with Guild Insurance Ltd, the latter organisation is heavily influenced by the PGA - an organisation dedicated to proprietor pharmacists.

Can they truly represent me in an impartial manner given that the PGA has taken steps to exclude all employee pharmacists from its umbrella organisation?

Even when a PDL error report form is completed, there is no room for the employee to fill in details that would represent a fair reportage of their side of the error.

And even if you draft a letter to better explain the situation, this would probably involve stating details that could aggravate your employer – or at the very least, cause a rift in the relationship.

There needs to be a separation of employer/employee interests here to avoid potential conflict of interest.

My next thought was a trade union, so I visited the website of the Pharmacist Division of APESMA (PDA) to see if they tailored legal and supportive services in the event of a dispensing error.

I could not find such a service.

Many errors have a workplace component due to faulty design or systems, and this type of problem is unable to be controlled by an employee/contractor pharmacist.

If a union is not involved at the workplace level in all aspects, then it is unable to claim that it can truly represent its members.

And given the emotive tone of the report identifying US pharmacist Eric Cropp, it may be necessary to have someone represent me when confronted by the media, another specialist service.

Any experienced pharmacist would well recognise the potential for stress in just changing a working environment, particularly where retail managers may be vested by the proprietor with a certain level of decision-making (that may be inappropriate, even unlawful). Also staffs tend to have the expectation that your work processes and decision-making will be identical to the proprietor - a common cause of friction and stress.

I have often been left unsupported by technician or sales assistant staff simply because it was a retail manager’s decision to let these people leave the premises for an errand of some sort, and then be presented with a rush of prescriptions with everyone wanting their’s immediately, if not sooner.

Add to the mix the requirement to answer a telephone or two plus the obligation to supervise an S3 sale, and focus is immediately lost.

The pharmacy does not necessarily have to have a high script volume for this to occur – only a collection of events coming together inappropriately for a few minutes, to cause a loss of focus, and the ultimate error.

Scanners have improved safety levels to a moderate extent.

However, there are some basic impediments:

* Scanners can sometimes bring up the wrong information

* Scanners cannot always be accessed if you are working beside a fast dispensing technician and the scanner is only attached to the dispensing computer.

Frustration sets in quickly.

I sympathise greatly with Eric Cropp who had to deal with a computer breakdown that generated a backlog of dispensing orders, and the corresponding pressure. Compounding the problem was a dispensary technician more concerned with planning her upcoming wedding than with compounding a cytotoxic preparation that contained sodium chloride.

You can almost sense that when Eric was checking that fateful script, he zeroed in on the cytotoxic ingredients and the dose of each, then by exception, ignored the benign ingredient of sodium chloride, a non-cytotoxic substance.

Eric Cropp’s error directly contributed to the death of the patient.

He was initially charged with reckless homicide but plea-bargained to a lesser charge of involuntary manslaughter.

Elizabeth Lee’s error did not contribute directly to the patient’s death, so she could only be charged for making a simple dispensing error.

But it was not that simple, as it could not be determined by the judge who had actually dispensed the drug. Elizabeth Lee was the pharmacist in charge and had to accept the legal responsibility.
The pharmacy was short-staffed with two of Elizabeth’s colleagues off on maternity leave. She was also fatigued, having to work 10 hour shifts regularly.

Both pharmacists were charged as criminals and received prison sentences.

Elizabeth Lee had her prison term suspended for 18 months while Eric will have to serve his.

Neither of these people were criminals in the sense that we would normally understand.

Most UK pharmacy organisations including The Royal Pharmaceutical Society want simple dispensing errors decriminalised, and this needs to be the case here in Australia.

In both the above error situations there was a strong element of having faulty workplace conditions to contend with.

Yet nothing was said about the pharmacy owners.

To what degree should proprietors have to bear their share of the error, and why were they not charged along with the pharmacists?

Perhaps they had better representation and support, being financially stronger.

What if a proprietor is a company?

Who goes to gaol?

All the directors?

I am simply asking the questions here because I have yet to research the full legal position.

While working my way through all of the above I could not find an external body that could routinely examine a workplace with the view to reducing incidents, be they involved with workplace safety, or the need for patient safety.

We have local councils, pharmacy boards, Workcover, PGA accreditors etc all having a look occasionally, but with a very narrow focus.

There is nothing routine that is also fair, and private.

As no overall review for patient safety takes place, (which would have to include appropriate working conditions for employed pharmacists) patients remain at risk and employed pharmacists bear the frontline responsibility.

It is all very well to say that if an employed pharmacist found an issue (that could eventually force that person into making a dispensing error), to discuss the matter with an employer, or simply leave.

Complaints of that type usually involve a cost for employers, and most employers try to avoid or defer that type of cost. Employees like to retain their jobs even within a difficult environment, and it should not be their direct responsibility to negotiate a safe environment or work practice.

So a “discussion” employee to employer to start with is a lopsided power structure that could lead to a “black list”, as has already happened in some Australian pharmacy groups and overseas retailers.

Until an organisation emerges that has as its charter to represent all employed/contractor pharmacists in legal, political and professional business matters, this segment of the pharmacist population will continue to be disadvantaged.

There is strength and safety in numbers (the nurses discovered that some years ago).

If anyone can make a positive contribution to the above, please make a comment in the panel below this item.

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