Why I am in ISMP's Camp and not the Ohio State Board of Pharmacy

The ISMP pieces are very well done and do not deserve these comments, from the Ohio State Board of Pharmacy, in their most recent newsletter (page 4). Links to the terrific non-biased pieces from ISMP are listed below.

The State board invokes the evidence card. What evidence is there that revoking license of a poor scared victim of the hospital system will protect the public? They are clearly reacting to a mob mentality, in my view. The evidence, if they bothered to look at the just culture literature, and plugged the facts into the algorithms of Just Culture, is the exact opposite of their Neanderthal actions.

One State Board member from another State has invoked 'facts not in evidence' to justify OH actions (personal communication). That to me is cowardly. Make a call on the facts in play. Good people can disagree, but we need to have this dialog more.

The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes -Lucian Leape

What is your view? Please read and view these before making up your mind:

ISMP references

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)

Really good write up in Wachter's World by noted Hospitalist Bob Wachter: Jail Time for Medical Error, Redux

Other posts of mine on this case [link]

Tags » Eric Cropp

25 February 2010
Views
5 Comments
Permalink
Tweet

about 2 years ago leetilson (Twitter) responded:

Unlike this pharmacist, Emily Jerry did not get out of jail after six months. Emily Jerry will not get out of jail in five, ten or even twenty years. Emily Jerry will not even have the chance to spend the rest of her life in jail. Emily Jerry, well, Emily Jerry got a death penalty. It was an accident, but she is just as dead. How would we feel if the pharmacist received the death penalty?

Of course he would not deserve it. Neither did Emily Jerry.

We need to re design medicine so that this NEVER happens again.There have been millions of these errors even though one is too many.

I am trying to obtain the transcripts of the hearings in court and before the licensure board. After learning of this case watching a CNN piece on it, I contacted Emily Jerry who advised me that the press accounts contain misinformation.

If the energy that is being directed towards denouncing this criminal prosecution could be employed towards solving this kind of mistake, we could stamp them out. Eliminate the dispensing errors..

We can eliminate the criminal prosecutions of pharmacists by preventing the errors like this that kill people. Preventing these errors is a moral imperative. A beautiful little girl dies and our outrage is directed towards the prosecution of a pharmacist who spends six months in jail. Anyone would choose the pharmacist's fate over Emily Jerry's.

Emily Jerry will not be the last two year old child to die of a medication error. There will be at least another ten, another hundred, and another thousand dead children. Are we willing to stop it?

Medication errors such as this one occur daily in America. People die. Had prior occurrences of this error been publicized, perhaps the problem with medication errors would have been solved. Perhaps publicizing such an error in 1994, or 1997, or even one in 2001 could have prevented Emily's tragic death. Imagine that the medication error of February 26 had been avoided. Emily Jerry would be alive. The pharmacist would not have been prosecuted.

Why wasn't Emily Jerry's death, in and of itself, sufficient to spark outrage over and publicity for the medical error that killed her? Our acceptance of such medical errors that kill beautiful two year old children and the fact that these events are almost never reported in the media has allowed the errors to multiply.

We must end the silence. We must express outrage over the death of this child. The moral imperative is to stop these mistakes. If the legal system is the only way to generate attention for these errors, we must use it. Lives are at stake.

At this point, I do not know enough of the facts to argue that the pharmacist deserved to be prosecuted. I am trying to get more information.

Emily Jerry did not deserve to die. Can we focus a little bit of our energies on preventing it from happening again? If the criminal prosecution causes us to do that, then something very good has come out of the prosecution.

If I am in error, kindly correct my false beliefs.

Lee Tilson
www.rethinkingpatientsafety.com

RxDoc.Org

Why I am in ISMP's Camp and not the Ohio State Board of Pharmacy

John Poikonen's Space

Archive

About John Poikonen

Follow Me