The greatest injustice in hospital pharmacy history and ASHP's Ambivalence on Principle and Failure to Act
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)
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Unfathomable....
I am a pharmacist who has always "bucked the system" and refused to take shortcuts in the name of speed. While some employers revered me and some even fired me because I followed the hospital policies that were invented to protect the patient, this is by far the most outrageous thing I have seen. Criminal prosecution? The mom in the case is understandably distraught and her emotional state weighed heavily on public opinion and the prosecution. ASHP should have stepped up to sway public opinion. Pharmacists for decades are the most trusted profession due to our committment to our patients. ASHP should've stepped in and then other professions' organizations should have also got involved. This is an incomprehensible legal precedent. If this had happened as a mistake from a dental assistant or Operating room technician or some other personnel under a licensed professional, I wonder what the results would have been? Pharmacists as a profession typically are sued less than other healthcare professions due to the systems that are in place. A blatant failure in a system and you are a criminal??
I'm choosing to get out of this profession and move to something more productive in helping people in their lives. I'm nervous for all those healthcare workers who endure the stress of having other people's lives and emotions in their hands and the public expectation for perfection....we're all human! Systems should help us along and in this case they seriously failed.
My best wishes to Eric, I've sent a personal letter that I hope reached him as well in the past on EFT. (Emotional Freedom Technique) and PSYCH-K. I hope the spotlight fades and you find your inner peace.
Pam, RPH in NC
The hottest place in hell
My mentor and spiritual advisor for many years when I lived in LA Tweeted this.
@marwilliamson "The hottest place in hell is reserved for those who, in times of crisis, preferred to remain neutral." -- Dante's INFERNO
I can not help think this applies to the hospital pharmacist organization, ASHP, and their leaders that preferred to remain neutral on the jailing of Eric Cropp.
Facebook group on Eric Cropp
It turns out that the Facebook page http://www.facebook.com/group.php?gid=80027824558&v=wall on Eric Cropp should not go to jail has as many members at ASHPFoundation. All I am observing is that this issue will impact membership at some point. I think it already has.
#fail for ASHP
It’s frightening to think that I could be in the same situation as Eric Cropp. I’ve been a hospital pharmacist for more than a decade and have made my share of mistakes. I’ve always assumed that my hospital and profession would come to my aid in the event of a serious one, but it now appears that I was naïve.
ASHPs lack of response during the Cropp case and their written response to Poikonen’s letter is very disappointing to say the least. It’s during these times that pharmacists need the support of ASHP, both in private and in public. This entire episode of events is quite the embarrassing black eye for ASHP if you ask me. It makes me question ASHP’s leadership; all pharmacists should question it.
Thanks for taking such an interest in this John.
Jail Time for Medical Errors
Dear Kasy K Thompson, Pharm. D., VP OPPC of ASHP
I have just read John Poikonen, Pharm. D's letter to ASHP entitled "Lack of clear statement and outrage from ASHP on Cropp case," in the 04-15-2010, Vol 67, issue of AJHP and would like to comment.
First, I couldn't agree more with Poikonen's letter. And it's not just ASHP. It's all of the pharmacy societies and organizations out there that are guilty of remaining silent or neutral or soft spoken on outrages like the Cropp case.
Second, I read your response and you offer ONE sentence regarding ASHP stance of criminial prosecution of pharmacists. While I greatly respect ASHP's & ISM's work on reducing med errors and creating a fail-safe environment for med use, which was the majority of your response, I just don't see any of our societies taking proactive stances, positions, leadership, or legislative initiatives, etc. against this horrible practice of prosecuting any health care professional, pharmacist or otherwise, for a mistake. I can't help but believe that Poikonen is right when he says, ASHP "takes a weak and noncommittal stance," when I only see ONE sentance in your entire response devoted to protecting pharmacist from criminal prosecution. The only sentence I saw was: "Further, ASHP will work with any of its state affiliates where laws exist or may be created that do not reflect the principles expressed in ASHP policy on patient safety and error reporting, including laws that make the criminal prosecution of unintentional erros possible."
Third, I'd like to see the ASHP and all the other pharmacy organizations, societies out there, nationally and state wide, take a proactive, positive, leadership role in making that sentance I just quoted above from ASHP happen now.
David Simsek, R.Ph.
POB 2061
Winnemucca, NV 89445
dasimsek@yahoo.com
Legal perspective
I have been involved in many cases of medical malpractice or negligence leading to the death of a person. Most of these targeted the physician caring for the patient. I also talk to attorneys quite a bit. To date I have not heard of a medical doctor being imprisoned for a professional practice mistake. My point here is the Medical community has safeguards in place to prevent criminal prosecution and imprisonment. Pharmacists should push for the same type of safeguards, and we can only accomplish this united as one.