Directly Speaking - Medication Errors: They're Everyone's Business

by Scott A. Meyers, Executive Vice President
January 11, 2013

The fallout from the New England Compounding Center contaminated products continues to reign down on pharmacy across the nation and here in Illinois. While I wouldn’t call that problem a true medication error, in several ways it is. More importantly, a medical error that drew national attention a few years ago was in the spotlight at this year’s ASHP Midyear Meeting. The Emily Jerry Story took center stage on Monday afternoon of the Midyear, and Emily’s father, Chris Jerry, the pharmacist involved in the error, Eric Copp, and Michael Cohen from ISMP all spoke candidly and emotionally of the impact that one error had on them, the State of Ohio and pharmacy practice in general.

For those who are not familiar with Emily’s story, she was a year and a half old, blond haired and energetic toddler that was diagnosed with a yolk sac tumor in her abdomen in 2005. By February of 2006, Emily had undergone successful surgeries and was ready for her hopefully last round of chemotherapy. It was the last treatment because tests had shown that the cancer was gone, but this was insurance to make sure that no traces remained. On the third day of her five-day treatment, Emily received a bag of chemotherapy that contained nearly 26 times the normal amount of sodium chloride that was prescribed. The hospital pharmacy compounded what should have been a normal saline bag from concentrated sodium chloride (23.4%) without proper dilution! The pharmacist was busy trying to catch up from an extended computer down time in the early morning and did not check the bag as thoroughly as he should have. The nurse had called for it “stat” somewhere around noon even though it was not due until 5:00 PM. The pharmacy technician that compounded the bag was very new and had not been thoroughly trained in the IV room. You can see the Swiss cheese holes lining up quickly. The saddest note was that because it was Sunday and supplies had not been replenished during the weekend, a simple bag of normal saline had to be compounded rather than merely taken from the shelf.

Emily succumbed to the complications related to the hypernatremia several days later. The Ohio Board of Pharmacy revoked Eric Copp’s pharmacist license and the local district attorney filed criminal charges that sent him to prison for more than one year. The pharmacy technician did not lose her registration because at that time, Ohio did not register or even recognize technicians. The hospital was not disciplined.

As I said, the presentations by Chris Jerry, Emily’s father, and Eric were emotional and moving. The fact that Chris has forgiven Eric and asked him to help in his new cause of preventing medication errors is amazing. Eric’s openness and honesty are commendable. It’s clear that he cared about helping others and never intended to do any harm let alone be part of an accident that caused a death.  

Because the NECC contamination issue was such a hot topic at the Midyear and because Emily’s story was so compelling and moving, it made me think about how both situations could have been prevented if everyone involved had done what they were supposed to do. In the case of NECC, a lot of people didn’t do their jobs. The Board of Pharmacy in Massachusetts, potentially the FDA, every buying group that placed their products on their contracts, and then most importantly, the pharmacists and technicians who worked at that facility all failed to do what should have been done. Drug shortages caused by other factors certainly didn’t help either. In Emily’s case, it was not only Eric and the technician, but the pharmacy managers who allowed normal saline bags to be compounded rather than restocking them from central supply, the nurse in a hurry for the bag, which caused undue stress on the pharmacy, the pharmacy staff for not stepping in to make sure computer down-time backlogs are not handled in a safer and more efficient way and hospital administration for not owning the error as a system error but instead placing the blame on the staff.

Medication errors can all be prevented if everyone does their job. Medication misadventures like adverse reactions to properly prescribed medications cannot. Medication errors seldom result from deliberate actions but often as a result carelessness or rushing. Many times medication errors can be prevented by simply speaking up, identifying an unsafe practice and proposing a safer alternative.  

I know this is easy to say if you’re someone who no longer deals with medications in general, but I felt moved by Emily’s story and by the negligence and greed of NECC to bring this issue up again. I know that I wouldn’t be afraid to speak up if I saw an unsafe practice, but I also know that I often became more concerned with churning out product in my days as a practicing pharmacist than I did about taking the proper time to make sure everything was correct. We all feel the pressure of doing more with less, but we can’t forget that at the end of the process is a patient that trusts us and relies on us to make sure their medication is correct and safe.

Medication errors should always be dealt with seriously and quickly to identify the causes, to improve systems and to prevent reoccurrences. Medication errors should only be treated as criminal offenses when they are done intentionally to cause harm. If a medication error does occur, it is the lesson learned from it that supplies the only value. Medication safety is everyone’s business.

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