CRIMINALIZATION OF MEDICATION ERRORScist’s license. 11 The vote was six infavor of this resolution with twoboard members in opposition.In May 2009, the pharmacistpleaded no contest to a charge ofinvoluntary manslaughter forimproperly supervising the technician.On August 14, 2009, Mr.Cropp was sentenced to 6 monthsin prison, 6 months of home confinementwith electronic monitoring,400 hours of community service,a $5,000 fine, and payment ofcourt costs. 12 Part of the communityservice sentence requires himto seek out medical and legalorganizations where he can tell hisstory and, hopefully, help preventothers from making a similar mistake.Remember that his pharmacistlicense was permanentlyrevoked, so he will have a significantloss of future income. Andthen, of course, there are the undisclosedattorney fees that the pharmacistincurred in his hearing infront of the Board of Pharmacy andhis criminal prosecution.Oh, and by the way, what happenedto the pharmacy tech thatmade the fatal error? Katie Dudashwas charged by the prosecutor withnegligent homicide, but the grandjury gave her a “get out of jail freecard.” She gets off with no realpenalty and is now working in aretail pharmacy. She was notlicensed, registered, or certified bythe state to work as a technician, sothere were no administrative sanctionsavailable. She has no accountabilityor responsibility. She was justan employee doing a job. She didnot do her job right, but there wereno consequences—other than losingher job and maybe having to livewith the idea that her actionsdirectly caused the death of anotherhuman being.Emily’s LawAt the time, Ohio was one of manystates that had no minimum training,licensing, registration, or certificationrequirements for pharmacytechnicians. State regulations varytremendously with respect to pharmacytechnicians. Currently, onlyeight states license technicians, 31states have registration, and fivestates certify techs. Twenty stateshave no educational requirements(training, continuing education, orcertification exam) for technicians. 13On January 7, 2009, the governorof Ohio signed SB 203, known as“Emily’s Law,” which establishesstandards for qualified pharmacytechnicians and requires them toundergo a criminal backgroundcheck. 14 They must also pass a competencytest. It also establishespenalties for certain activities,including compounding, packaging,and preparing a drug by an individualwho is not a pharmacist, pharmacyintern, or qualified pharmacytechnician. 15The downside of making thismistake, awful as it was, into acriminal case with incarcerationfor the offender is that it discouragesothers from ever wanting toreport errors with serious consequences.“We need to change thesystem. I’m hopeful that we canfind something meaningful interms of safety from this child’sdeath,” said Bona Benjamin, directorof medication use qualityimprovement at the AmericanSociety of Health-System <strong>Pharmacist</strong>s(ASHP). 16 Some pharmacygroups are beginning to push forgreater standardization of techniciantraining. ASHP has developeda model curriculum for pharmacytechnician training programaccreditation as the first effort todevelop a national standard. Inaddition, the National PharmacyTechnician Association, the Institutefor the Certification of PharmacyTechnicians, and the PharmacyTechnician CertificationBoard have all worked to developtechnician training standards. 17If nothing else, this case shouldsend a loud and serious message topharmacists. You can delegateactivities associated with the practiceof pharmacy to technicians andothers. But you can never delegateresponsibility or accountability. Itis your name on the license, andthere are no excuses for mistakes ofthis type.REFERENCES1. Emily’s Story. Emily Jerry Foundation.http://emilyjerryfoundation.org/emilys-story/.Accessed October 11, 2009.2. Robins M. Fatal dose: Ohio girl is killed by medicalmistake. January 31, 2007. www.firstcoastnews.com/news/usworld/news-article.aspx?storyid=75102.Accessed October 4, 2009.3. Whitley M. Chris Jerry, whose daughter Emily diedfrom a pharmacy technician’s mistake, starts foundation topush for national law. June 13, 2009. http://blog.cleveland.com/metro/2009/06/chris_jerry_whose_daughter_emi.html. Accessed October 11, 2009.4. News. Emily Jerry Foundation. October 7, 2009.http://emilyjerryfoundation.org/chris-jerry-whosedaughter-emily-died-from-a-pharmacy-techniciansmistake-starts-foundation-to-push-for-national-law/.Accessed October 11, 2009.5. See note 4, supra. The Web site states, in part: “Thecore of the Emily Jerry Foundation focuses on protectingour nation’s babies and children from the all too redundantmedical errors that keep occurring over and overagain in hospitals across the nation. These countless mistakesare killing our children and are most often avoidable.We are increasing public awareness of these issues andstriving to get better legislation in place across the UnitedStates. The Emily Jerry Foundation is helping to savecountless lives, as well as make our world-renowned medicalfacilities much safer.”6. See note 4, supra.7. Failure to track pharmacy mistakes may be“prescription for trouble.” NewsNet5. March 23, 2009.www.newsnet5.com/news/18917359/detail.html.Accessed October 11, 2009.8. Minutes of the April 9-11, 2007 meeting of the OhioState Board of Pharmacy. Docket Number D-061108-012.http://pharmacy.ohio.gov/minutes/mins07040911.pdf.Accessed October 11, 2009.9. ORC § 3715.52(A)(2) and OHC Rule 4729-17-10.10. See note 8, supra.11. ORC § 4729.16.12. Not a wonderful life: no George Bailey for pharmacistEric Cropp or his patient. September 5, 2009.http://jparadisirn.com/2009/09/05/not-a-wonderful-lifeno-george-bailey-for-pharmacist-eric-cropp-or-his-patient/.Accessed October 4, 2009.13. Reid P. Former pharmacist indicted for manslaughterafter med error. Drug Topics. September 17, 2007.http://drugtopics.modernmedicine.com/drugtopics/Community+Pharmacy/Former-pharmacist-indicted-formanslaughter-after-/ArticleStandard/Article/detail/456584.Accessed October 11, 2009.14. Sangiacomo M. Ohio governor signs “Emily’s Law”forcing standards for pharmacy technicians. ClevelandPlain Dealer. January 7, 2009. www.cleveland.com/medical/index.ssf/2009/01/emilys_law_enacted_by_gov_stri.html. Accessed October 11, 2009.15. Governor signs “Emily’s Law” legislation.www.governor.ohio.gov/News/PressReleases/2009/January2009/News1709/tabid/956/Default.aspx.Accessed October 11, 2009.16. See note 13, supra.17. See note 13, supra.68U.S. <strong>Pharmacist</strong> • November 2009 • www.uspharmacist.com
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