We are all Eric Cropp and RaDonda Vaught

Pharmacist and Nurse criminally prosecuted for medication errors caused by system failures. Dramatically different responses from professional organizations.

Eric Cropp and RaDonda Vaught have been criminally prosecuted for medication errors. Their types of errors were unfortunate. Their circumstances are encountered every day by pharmacists and nurses. Prosecuting them criminally is wrong on so many levels.

Eric Cropp

A pharmacist was prosecuted and jailed for a medication error that was clearly a breakdown of the system. While a practicing hospital pharmacist, I was in the exact conditions Eric Cropp was in many times. I am human and am sure I made mistakes. Thankfully I am not aware of killing anyone. As a pharmacy director I have presided over a hand full of harmful mistakes by staff. I have changed systems to insure they are minimized. I have known many Eric Cropps.

RaDonda Vaught

Now a nurse was prosecuted for a medication error that also was clearly a breakdown of systems and technology. Here is a good audio summary of the incident. Below are some summaries of the case that do a great review.

Response from Professional Organizations

Previously I have written on the disgraceful response by the primary hospital pharmacy org, Am Soc of Health-System Pharmacists (ASHP). The greatest injustice in hospital pharmacy history and ASHP’s cowardly and disgraceful response. ASHP continued their complete lack of courage and support for the recent criminal prosecution of a medication error.

This is ASHP’s feeble response to the LaDonda Vaught incident. ASHP’s lack of outrage, support and solution orientated approach is shocking and down right evil. ASHP is not a professional organization, they are a CE money making machine. Nothing wrong with that, it is just that they put up a false mission that they support health care professionals. They should be prosecuted for malpractice.

The Institute for Safe Medication Practices (ISMP) on the other hand has handled these incidence with style, grace, empathy and in a solution orientated manner. This is what an organization that cares about patients and health professionals is suppose to do. ISMP’s CEO is a MacArthur Fellow awardee, Micheal Cohen. He supported Eric Cropp in advocacy and policy. He reached out to Mr Cropp many times and visited him in prison. This is what a professional with empathy does to support injustices.

ISMP’s clear and consistent reporting and solution approaches to the medication error and criminal prosecution of RaDonda Vaught is inspiring.

In summary here are the professional societies responses:

The Institute for Safe Medication Practices.

https://www.ismp.org/resources/tn-board-nursings-unjust-decision-revoke-nurses-license-travesty-top-tragedy

https://www.ismp.org/resources/another-round-blame-game-paralyzing-criminal-indictment-recklessly-overrides-just-culture

https://www.ismp.org/resources/safety-enhancements-every-hospital-must-consider-wake-another-tragic-neuromuscular

https://www.ismp.org/resources/paralyzed-mistakes-reassess-safety-neuromuscular-blockers-your-facility

Versus

https://www.ashp.org/news/2022/03/29/ashp-response-to-criminalization-of-medication-errors

For my fellow complacent pharmacist colleagues, 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. You can insert Nurse as well as Pharmacist here:

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 un-remorseful 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.

Brief Informatics View of the incident.

Automated dispensing cabinets are set up to prevent errors. In this case, from what I have been able to gather, they were not working the way it is intended. The IT staff bears some responsibilities in this horrible incident.

Bar-code medication administration (BCMA) would not have prevented this death. Over rides of the inconsistent bar codes as with the dispensing cabinets is a common practice for nurses. BCMA still lacks a single good study that shows better outcomes. A colossal waste of time and money in our hospitals.