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Criminalization ofMedication ErrorsA recent casethat equates apharmacist’s mistakewith manslaughteralso raises thequestion ofpharmacy technicianresponsibility.Here is a sobering thought.A pharmacist makes a mistake.The error results inthe death of a patient, and the pharmacistis charged with negligenthomicide. He is found guilty ofinvoluntary manslaughter and facesup to 5 years in prison and a maximumfine of $10,000. Of course,his pharmacist license is revokedand chances are he will never workin the profession again. His crime?He did not check the accuracy ofcalculations used by a pharmacytechnician under his charge to compoundthe concentration of sodiumchloride in a prescription for a cancerchemotherapy solution.Negligent? Yes. Accountabilityand responsibility? Yes and Yes. Malpractice?Yes. Loss of license? Yes.Guilty? Yes. But a crime? Prisonterm? For a mistake, albeit a mistakewith a worst-case outcome? That istough medicine to swallow. MoreJesse C. Vivian, BS Pharm, JDProfessor, Department of Pharmacy PracticeCollege of Pharmacy and Health SciencesWayne State UniversityDetroit, Michiganimportant, how is justice served byputting this pharmacist in jail? Themessage to pharmacists and perhapsall other health care practitioners—watch out. There may be prosecutorsout there just itching to putyou away.Facts of the CaseOn February 24, 2006, while workingat the Rainbow Babies andChildren’s Hospital in Cleveland,Ohio, licensed pharmacist EricCropp received a prescription for achemotherapy solution of Eposin(etoposide phosphate) that was supposedto be mixed in an IV bag ofnormal saline containing 0.9%sodium chloride. 1 The patient,Emily Jerry, was diagnosed with ayolk sac tumor when she was abouta year and a half old. The tumorwas the size of a grapefruit andstemmed from the base of her spineinto her abdomen. Her team ofdoctors and nurses assured the parentsthat Emily’s cancer was notonly treatable but curable. Emilyendured months of surgeries, testing,and rigorous chemotherapy sessions,each of which lasted for 5 or6 days. Emily’s treatment had beenso successful that her last MRIclearly showed that the tumor hadshrunk dramatically, with minimalresidual scar tissue. However, herphysicians still felt one final treatmentwas necessary to prevent thetumor from reappearing. She wasscheduled to begin her lastchemotherapy session on her secondbirthday. This last treatment wasjust to be sure that there were notraces of cancer left.The medication was to be thefourth and final round of treatment.Two days later, after the IV therapywas started, the child collapsed inher mother’s arms, crying in painand vomiting. She grabbed her headand said, “Mommy, it hurts, ithurts.” The IV was started at 4:30PM. By 5:30 PM, she was on life support.She went into a coma anddied on March 1, 2006. 2 The infusioncaused intense cerebral edema.For reasons that have never beenexplained, the technician who madethe mixture, Katie Dudash, used asaline base solution of 23.4%sodium chloride instead of the commerciallyavailable standard bag ofnormal saline. She told investigatorsthat she did not recall why shedecided to make a new solution ofsaline from scratch instead of grabbinga premade bag of normal salinethat was available right there in thepharmacy. She said she was distractedbecause she was talking onher cell phone just before the incidenthappened, busy making plansfor her upcoming wedding.An investigation into the incidentdisclosed that many circumstancescontributed to the error’soccurrence. The pharmacy computersystem was not working and abacklog of physician orders was pilingup. The pharmacy was shortstaffedand everyone in the pharmacywas busy. The employeeshortage meant that normal workand meal breaks were altered or notavailable. The technician was distractedfrom her normal routine. Afloor nurse called the pharmacy andasked the pharmacist to send the66U.S. Pharmacist • November 2009 • www.uspharmacist.com