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I am a bit perplexed by the lack of outrage and action on the jailing of Eric Cropp for a system error.  Perhaps some do not think this is the case to speak out on due to some grey areas.

Please allow me to paraphrase a famous quote from Martin Niemöller (1892–1984). http://en.wikipedia.org/wiki/First_they_came   With respect for Pastor Niemöller:

THEY CAME FIRST for an incompetent pharmacist, and I didn't speak up because I am not incompetent.

THEN THEY CAME for a pharmacist for making errors, and I didn't speak up because I do not make errors.

THEN THEY CAME for an unremorseful pharmacist, and I didn't speak up because I am remorseful.

THEN THEY CAME for me, and by that time no one was left to speak up.

At different times in following the Eric Cropp case a few items came up that caused me to reflect on the paraphrasing above.  It was whispered that he was an incompetent pharmacist, given all of the errors he made.  Most of his errors came after the tragic mistake that caused the death of a child.  His distress was such that other mistakes were made.  His emotional health was not addressed from what I understand.  He seemed “unremorseful” was an additional comment that was made in some of the reports.  None of these unfortunate things justified his license being revoked, and certainly do not justify the criminal prosecution. 

Please speak up forcefully, loudly and unequivocally for a just culture.

Warning:  This post is not about informatics.  It is about the greatest injustice in hospital pharmacy history and the organization that represents that profession.  The case involves the jailing of a pharmacist for a system error.  Numerous facts and details of this injustice can be found in the links below and in some of my other writings.

First, here is my perspective.  I have been a hospital pharmacist in one capacity or another for 30 years that has made and presided over, as a manager, many medication errors.  Some that have caused horrible harm and suffering.  I am active and have been elected to leadership positions in many professional organizations including the one I will criticize here, the American Association of Health System Pharmacists (ASHP).

The stellar, admirable and heartfelt response to this case by Michael Cohen and the Institute for Safe Medication Practices (ISMP) is an example of a commitment to a principle, regardless of how it looks or the consequences (links below). 

ASHP calls itself a membership organization.  It seems to me they should support their constituency in the dark hours of injustice.  A membership organization should rise up and defend their constituency against injustices, the way Nursing organizations have done recently.

ISMP’s and Nursing member organization responses to injustice is strikingly different than the repulsive ‘head in the sand’ approach by ASHP.

When this error occurred and criminal prosecution went forward, I contact the President and two board members of ASHP inquiring on what the organizations response will be.  They indicated that they would respond quickly to this injustice.  There was no response and nothing happen for almost a year.  It was not until I submitted a letter to their official journal, AJHP, asking for action, that the response came.  [Link to ASHP Response]

The ASHP response to the Eric Cropp case contains a cowardly mischaracterization about the case.  Dr. Thompson indicates that ASHP “does not and will not have access to all of the facts” therefore will not comment. The facts of the case are very public and available in the form of court and pharmacy board transcripts, numerous news articles, attorney commentary, interviews of Eric Cropp, route cause analysis and very detailed webinar by ISMP (see below).   Why ASHP would not seek out these facts is beyond belief. 

Insinuated here and others have secretly whispered to me that “oh, you do not know all of the facts of the case, if you did you would not feel the way you do”.  To me, that is someone wanting to feel superior and justify the mob mentality that took over in this case.  I have also gotten numerous communications on this case in support my views; that this case really was a system error.  With so much public information this whispering behind the curtain is not valid on either side of the case.  A membership organization should have the spine to make a call on the public information or even get up from the desk and do a little leg work to find out information that maybe lacking.

Additionally what I get from the Dr. Thompson’s response is that ASHP is committed to and has done many organizational and policy things in the name of patient safety and Just Culture.  These are commendable.   It is the lack of putting these think tank policy actions into action that I find disgraceful.

Using the facts of the case and applying the basic principles of Just Culture brings you to the clear conclusion of a gross miscarriage of justice.  Even the father of the dead infant came to this inevitable conclusion.  It is surprising for a professional organization not to seek out these readily available facts and apply the principles they supposedly hold so dearly in this individual case. 

Not seeking the readily available facts of the case draws me to the conclusion that while ASHP works on a high level policy, when it comes to individuals, where these policies have a real impact, they hide behind a cowardly veil of “facts not available”.   

The fact that ASHP focuses on organizational initiatives but fails to act on an individual case of a hospital pharmacist injustice is what strikes me as weak, noncommittal and disgraceful for a hospital pharmacy membership association.

Lucian Leape, in testimony before Congress on health care quality improvement stated “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”  ASHP’s complete lack of action and turning a blind eye to Eric Cropp will set us back years.

What say you?

Background and Reference Links

Wachter's World by noted Hospitalist Bob Wachter: Jail Time for Medical Error, Redux 

http://www.ismp.org/pressroom/Judge_Corrigan_07-13-09.pdf 
http://www.ismp.org/Newsletters/acutecare/articles/20090827.asp 
http://www.ismp.org/Newsletters/acutecare/articles/20091203.asp 
http://bit.ly/cqsy76 (Webinar Replay)

The following is the story of Eric Cropp, the pharmacist that was jailed because of a medication error.  It is an article well worth reading: http://www.ismp.org/Newsletters/acutecare/articles/20091203.asp  What is your stance on Eric Cropp and what are you doing about it?

At a legal lecture recently, an attorney flatly stated to a crowd of residents that they should not even consider practicing in the State of Ohio, due to the egregious actions of the Ohio State Board of Pharmacy and Justice System.  Sorry for those that practice in Ohio.  Frankly, this sounds like good advice.

At the 2009 ASHP House of Delegates a Statement in support of a just culture, excerpt quoted below, was passed unanimously.  The absence of ASHP speaking out clearly,loudly and forcible on this injustice is egregious.  An ASHP press release on the trivial matter of the TV show ‘Nurse Jackie’ and silence on this issue strikes me as a lack of leadership, abandonment of a central value of practice and not supporting hospital pharmacists.  I have privately and publicly asked that this be addressed.  Please join me in asking ASHP leadership to speak out unequivocally in support of the policy of a just culture and the gross injustice done to this hospital pharmacist.

“To encourage pharmacists to exert leadership in establishing a just culture in their workplaces and a nonpunitive systems approach to addressing medication errors…”

Please join me in writing to Eric Cropp while he is in prison to show your support of a fellow pharmacist.  As I said in a lecture recently "It is only by the by the grace of God, you or I are not wearing a orange jump suit". Eric Cropp (S.O. 266577), Cuyahoga County Jail – Pod 7G, P.O. Box 5600, Cleveland, OH 44101 (Release is scheduled Febuary 14, 2010)