By Eric Cropp.
It was a busy Sunday in the pharmacy at Rainbow Babies & Children’s Hospital in Cleveland. The hospital’s computer system had been down for about ten hours before I started my shift, and because I was teamed with a pharmacist who was fairly new to the department, I had additional responsibility. But I’d been in busy situations many times before. In fact, I had 14 years of experience and had been president of the Northern Ohio Academy of Pharmacy.
But on this day, I made the mistake of not thoroughly checking a saline-solution base that a technician had prepared for a child’s chemotherapy treatment. She mixed it more than 20 times stronger than ordered, and I didn’t catch it. When a nurse administered it, the high concentration of sodium chloride flowing through the child’s veins made her brain swell and put her in a coma. Three days later, she died. Her name was Emily, and she was two years old.
I was eventually convicted of involuntary manslaughter, for which I received six months of jail time, six months of house arrest, three years of probation, a $5,000 fine, and 400 hours of community service. I also lost my license, career, reputation, and confidence. But most devastating of all is that I have to live every day with the memory of that little girl.
I accept full responsibility for what happened. I should have checked that solution more carefully. But there are some facets of hospital and retail pharmaceutical work that desperately need fixing if similar tragedies are to be avoided.
Pharmacy technicians need better training. Most people don’t realize that techs have something to do with approximately 96 percent of prescriptions dispensed in pharmacies, according to the National Pharmacy Technician Association (NPTA). Yet 92 percent of us live in states that do not require them to have any formal training. (The tech in my case had a high school diploma.) Ohio recently adopted Emily’s Law, which requires that all techs undergo training and pass a competency exam. The NPTA is currently working on a bill that would institute Emily’s Law nationwide.
We should also take advantage of technology. There are lots of look-alike, sound-alike medications that come in small vials with tiny labels. A bar-code scanning system, like the ones in supermarkets, would supply an extra layer of safety.
But technology isn’t enough; pharmacists and techs need better working conditions. Pharmacies can be cramped and the workload is often heavy. But studies suggest that crowding and dim lighting make mistakes more likely. So do interruptions, and the need to fill too many prescriptions. Believe me, a lot of pharmacists say a little prayer on their way home that an error didn’t slip through.
Finally, I wonder what would have happened if I had talked to Emily’s family right away and said I was sorry. I was advised against doing that. That’s the way it is in the medical world when a mistake occurs: Hospital management may meet with the family, but the health care worker is often advised not to make a personal apology. Too much of a culture of silence still exists and must change. Doctors, nurses, pharmacists, and others need to be able to come together to confess their mistakes, clear their consciences, be supported, and, most important, work together to make the system safer.
*Names changed to protect privacy.
The above story was originally published by Readers Digest.
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