Directly Speaking - Is Pharmacy Compounding Headed for Its Own Cherry Mine Disaster of 1909?
by Scott A. Meyers, Executive Vice President
June 3, 2013
In late April, my wife scheduled a family field trip (She and I and both of my parents) to Malden, Illinois and a supposedly cute restaurant with great food. Well the restaurant was cute in a country sort of way and the fried chicken was good but the overall experience left a little to be desired considering the hour and 15 minute drive to get there. But part of the purpose of the field trip was to be the journey home. Not on interstates like we took to get there, but on county roads, state roads and even a U.S. highway (yes, they still exist outside the interstate system).Heading north and east in a zigzag pattern having traveled more than 80 miles south and west to get to Malden (northeast of Princeton, Illinois and north of I-80 for those wondering) we quickly saw two significant sized mounds in a small town in the distance that normally indicate a coal mine existed there at one time. As we rounded the curve on Illinois 89 and entered town (Cherry, Illinois) from the south we spotted a large monument (large for a small town anyway) and a sign that read Cherry Miner’s Cemetery. Possessing an i-phone and having heard a little bit about this town from the recommender of Malden’s Feed Store Restaurant, my wife quickly Googled Cherry Mine Disaster and relayed the following story.
In 1905 the Cherry Mine had been opened by the Chicago, Milwaukee and St. Paul Railroad to supply coal for their trains. On November 13, 1909 the mine was operating three horizontal shafts using nearly 500 workers, both men and boys, some as young as 10 years old. The mine was a modern mine using electricity to light it, but the electrical system had failed earlier in the week so the miners were using kerosene lanterns and torches to light their work areas. A coal car full of hay for the mules working the mine was poorly place below a lit torch and soon there was a terrible fire. The mine walls and ceilings were shored up with wooden beams and the coal walls were also flammable. The fire quickly spread out of control and eventually 259 men and boys were lost including 12 rescue workers who made six successful trips into the mine to save trapped miners only to perish on the seventh trip. Twenty-one miners survived in the mine for eight days by walling themselves off from the fire and drinking water that ran from a coal seam.
What happened following the disaster was hugely significant. The next year, the Illinois Legislature established stronger mine safety regulations and in 1911, the General Assembly developed Illinois’, and the nation’s, first Workmen’s Compensation Act. (I guess the General Assembly actually accomplished important things back then!)
The Cherry Mine Disaster is the nation’s third deadliest coal mining accident and until our April field trip, I personally had never heard of it! But now that I have, and have had the chance to reflect how safe, clean and easy my life is, some similarities have come to mind that I hope are worth sharing.
Fast forward to the NECC Disaster of 2012. That debacle has cost 53 lives and infected a total of 733 across 20 states. The causes of this are carelessness and unsafe conditions, just like in the Cherry Mine. Unsafe conditions for the production of the products being manufactured. And at that scale, those products were being manufactured! Because of the NECC Disaster, Congress is now considering sweeping changes to the purview and the powers of the FDA. Multiple State Boards of Pharmacy or related agencies are working to create stricter pharmacy compounding statutes and regulations. Many States already require compliance with USP’s Chapter 797, a recognized national standard. Many hospitals and health-systems are working to achieve compliance to 797 even though their State regulators (like Illinois) don’t require such strict regulation and quality control.
On the other hand, I have been in contact with a physician leader from one of Illinois’ larger health-systems who shared with me that because the State of Illinois does not require compliance to 797-like standards, the health-system’s engineering department will not budget the funds to re-engineer the system’s several hospital pharmacies’ air control systems and facilities to better reach a quality level necessary to provide safe patient care! This is a physician champion not a director of pharmacy! Even working with and for the pharmacy departments and directors together they can’t get the necessary changes made because of the bottom-line. For this health-system and many of the State’s individual hospitals, is something like the Cherry Mine Disaster just around the corner?
Will it take a change in State statute and regulation for your department to move toward safer patient care? Or are you already working toward it or better yet, there? Do others have to die or even suffer needlessly before the changes are made in Illinois and around the country to protect our patients? Or will the changes that are made be the ones we want and need or will the pendulum swing too far and move compounded products out of reach of many who need them?
Let me know where your pharmacy is on the road following the NECC Disaster. Tell me when you reached compliance or why you aren’t making the move toward it right now. Tell me why you can’t or haven’t gotten involved with ICHP’s efforts to draft new regulations for a safer sterile compounding system for Illinois patients. If nothing else, tell me you read this article and learned something about Illinois history today!
Don’t let Illinois hospital compounding experience another disaster like the NECC Disaster! Don’t let Illinois pharmacy have its own Cherry Mine Disaster!