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CRIMINALIZATION OF MEDICATION ERRORSsolution early. As a result, he feltrushed. Ironically, it was later determinedthat the IV bag was notneeded for several hours.As can well be imagined, thisincident took a terrible toll on theparents. They sued the hospital formalpractice and obtained a $7 millionsettlement. 3 Soon afterward,the parents separated, and theydivorced a year later. The mother,Kelly Jerry, had to obtain restrainingorders against Emily’s father, ChrisJerry. He violated at least one of theorders and lost custody of both ofhis other children. In 2008, he wasarrested for possession of marijuanaand charged with resisting arrest.His case was diverted to a mentalhealth court for sentencing. Hesought psychological counseling ashe looked for a way to workthrough his problems.Then, in 2009, Chris Jerryfound a way to make something outof this tragedy. Mr. Jerry begancounseling families in local hospitalswhose children were on life-supportsystems. He made himself presentsimply as one who understandswhat they were going through. “Ican speak to these people because Ihave gone through something similar,I know what they need to hear,”he said. “I can relate to them inevery way.” 4 He also started Emily’sFoundation, a charity he hopes touse to push for a national law togovern the work of pharmacy techniciansand help prevent medicalerrors like the one that killed hisdaughter. 5Kelly Jerry attended all of thecivil and criminal proceedings andmade a compelling statement at theboard of pharmacy hearing on theadministrative complaint against thepharmacist. Chris Jerry did notattend any of the legal actions,although now he no longer feels anyanger against the pharmacist. In facthe has been quoted as saying, “I feelvery sorry for the pharmacist. Thisguy is facing a prison sentence, andI know it was an accident.” 6Unprofessional ConductThe pharmacist and the technicianwere dismissed by the hospitalabout 1 month after the incident.The tech went to back to work atCVS/pharmacy where she had beenemployed before working at thehospital. The pharmacist found ajob at a local retail pharmacy just afew weeks later. There, according torecords, he made an additional 13more dispensing errors over a 10-month period. One of those errorscaused harm to another child. 7The Ohio State Board of Pharmacyheld a hearing on a formalcomplaint against the pharmacist onApril 11, 2007, a little over a yearafter the incident that caused thedeath of Emily Jerry. 8 For this error,Stateregulations varytremendouslywith respectto pharmacytechnicians.the board found him responsible formisbranding and mislabeling a drugin violation of Ohio law. 9 But thisincident was actually only thebeginning of Mr. Cropp’s problems.On April 26, 2006, while workingat a community pharmacy, EricCropp misbranded a prescriptionfor Compazine (prochlorperazine)10-mg tablets prescribed for “nauseaand vomiting.” 10 He typed thelabel indicating the medication wasto be taken “as needed for pain.”While at the same store, on July 18,he dispensed tramadol with acetaminopheninstead of the prescribedVicoprofen (hydrocodone andibuprofen). On July 25, he dispensedmetformin ER 500-mgtablets to a patient instead of theBiaxin XL (clarithromycin) 500-mgtablets that were prescribed. Onthat same day, he gave the Biaxin tothe patient who should have beengiven the metformin. On August18, he received a prescription forPhenergan (promethazine) 25-mgsuppositories with directions to beused “rectally every 8 hours.”Instead, he typed a label indicatingthe medication was to be “taken bymouth.” On September 19, he dispensedAdderall XR (amphetamineand dextroamphetamine) 5-mg capsulesto an 8-year-old child whohad been prescribed Focalin XR(dexmethylphenidate) 5-mg capsules.The child suffered undisclosedinjuries. On November 13,he received a prescription for Disalcid(salsalate) 500 mg. He dispensedAzulfidine (sulfasalazine)500 mg instead. On November 18,he received a prescription for VoSolHC (hydrocortisone and aceticacid) from an ear, nose, and throatphysician with indications that themedication was to be used “in theear.” He labeled the drug as for use“in the eye.” On December 12, hereceived a prescription for Zoloft(sertraline) 100-mg tablets withdirections that the patient shouldtake “two tablets every evening.”He labeled the medication to betaken “twice daily.” On December15, he received a prescription forAvelox (moxifloxacin) 400 mg. Helabeled and dispensed the drug tothe wrong patient. On December26, he received a prescription forZoloft (sertraline) 100-mg tablets.Instead, he dispensed 50-mgtablets. On February 3, 2007, hereceived a prescription for E.E.S.(erythromycin ethylsuccinate) 200mg/5 mL suspension. Instead, hedispensed erythromycin with sulfisoxazolesuspension. Finally, onthe following day, he received a prescriptionfor two boxes of Imitrex(sumatriptan) 6 mg/0.5 mL anddispensed a quantity less than whatwas called for by the prescription.The Ohio Board of Pharmacyfound that all of the above conductconstitutes “unprofessional conduct”in violation of state law and thenpermanently revoked the pharma-67U.S. Pharmacist • November 2009 • www.uspharmacist.com