Here's one to ponder and comment on – does putting a pharmacist in jail for six months and ruining his career and life do anything to bring back a two year-old girl? Does it do anything to make future patients any safer? Watch this video from CNN about Eric Cropp, an Ohio pharmacist who was convicted and put in jail for six months after a fatal process error…
For those who can't see the video, there's a transcript of the story here (scroll down or search the page for Cropp).
From the story:
In 2006, Eric Cropp was a pharmacist at a Cleveland hospital when 2-year-old cancer patient Emily Jerry was killed by the medical error of a pharmacy technician. She was given a chemotherapy drug mixed with a salt solution 23 times more concentrated than the normal dose. But because Eric Cropp was the supervising pharmacist and should have caught the mistake, he was sent to jail. And that's where I found him, confused, and struggling with regret.
My sense of outrage is overwhelmed by my sense of sadness over this whole case, between the tragic death of the little girl, Emily Jerry (more about the case and the girl), and about how the reaction does nothing to make other patients safer. I've started to blog about this a few times and I've kept putting it aside… even if I can't muster the full energy that this deserves, I'll put the video and the link out there, you can comment.
I don't think I have to belabor the point for Lean thinkers. I agree with the quoted patient safety experts who say that punishment like this will do nothing but force future problems underground. People would rather cover up problems than risk jail… that's not good for anyone. That doesn't bring back the little girl.
MATTINGLY: Cropp says the mistake that killed Emily Jerry came on a day when he was overloaded and rushed. These are common complaints throughout the nation's medical system. Patient safety advocates warn that cases like this might actually make it harder to change the conditions where tragic errors are made.
MICHAEL COHEN, INSTITUTE FOR SAFE MEDICAL PRACTICE: People are going to be afraid to come forward and identify problems that they've been involved with. Because of fear for losing their license, or, you know, in this case, even have criminal charges brought against you.
MATTINGLY: Michael Cohen for the Institution of Safe Medication Practices was among the advocates calling Cropp an easy target, saying the greater good is served by focusing on system issues that allow tragedies like this to happen. But in the court's eyes, Cropp had no excuse for missing the mistake that killed Emily Jerry. He's serving six months for involuntary manslaughter.
It *feels* good, maybe, to put a guy in jail… to hold him accountable, possibly to make an example of him. Cropp claims he was overworked and the pharmacy was chronically understaffed. Has a CEO or other hospital leader ever been convicted for systemic problems in a hospital? Whose fault is it if the pharmacy is overworked? Who goes to jail for that?
You might also remember this case I blogged about, in 2006, where an error a Wisconsin nurse was involved in was criminalized. Again, does that really help?
More about the story: USA TODAY, Modern Medicine, American Society of Hospital Pharmacists, US Pharmacist
UPDATE: Please listen to my podcasts with Chris Jerry, the father of Emily Jerry:
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Where is the evidence that he was overworked? That he was rushed?
What if he simply “made a mistake”? What if he misread something? What if he was incompetent? What if he did it on purpose?
This blog seems to blame management a lot. Where is worker accountability? In the end, what responsibility do workers have? To do what management tells them to do? Or, to not kill people?
What if he was overworked? Doesn’t he have a responsibility to tell someone he was overworked? Person A and Person B can be doing the exact same tasks at the same exact speed yet Person A may be overworked and Person B is not overworked. You expect management to garner that information?
You indicate that blaming the pharmacist may not be the best solution but, hey, let’s blame the CEO. That will really improve things.
Let’s try to stay focused on lean and improvement and reduce the class warfare.
Fred – Thanks for your comment, but I couldn’t disagree with you more. I’m not engaging in class warfare. I don’t think throwing anybody in jail would be helpful.
Rather than “blaming” management, I’m trying to emphasize that the CEO has more responsibility to create an environment where people can do quality work. That’s why they get the big bucks, they have more responsibility for the system.
You asked: “Person A and Person B can be doing the exact same tasks at the same exact speed yet Person A may be overworked and Person B is not overworked. You expect management to garner that information?”
Yes, I do. It’s called basic supervision and management 101.
I’ve seen too many hospital settings where people DON’T speak up about being overworked. Why? Because they’ve tried and managers don’t listen. So they give up. You can say shame on them all you want, that’s reality. Too many hospitals base staffing levels on things that are totally disconnected from reality (benchmarks or other financial targets). Managers aren’t “at the gemba” as we’d say in Lean so they don’t see the stress, their heads are in the sand. People have responsibility, but I’ve seen too many people labeled a “troublemaker” for trying to speak up in the name of quality – was he supposed to fall on his sword and quit if it was indeed a routinely overworked environment?
I doubt the court really proved that Cropp intentionally harmed that girl. Neither of us were there, you’re right, but I completely understand how a systemic error could have occurred… and the pharmacist is put in the role of inspector. We know from science that 100% human inspection is never 100% reliable. That’s a bad process if it relies on people catching errors. We’re human, we can’t catch everything.
As Gary Convis said at Toyota — “You respect people,” he said. “You listen to them, you work together. You don’t blame them. Maybe the process was not set up well, so it was easy to make a mistake.” — That isn’t the mindset at most hospitals and it’s a big reason why quality suffers and patients suffer. Management isn’t managing properly.
Now the U.S. Pharmacist piece details the dozen+ errors that Cropp was involved in, working at a retail pharmacy, after the death of Emily:
http://www.uspharmacist.com/content/c/16572/
Let’s say each error was solely his fault — who is managing the situation? Why wasn’t anyone pulling the proverbial “andon cord” if Cropp was indeed a bad pharmacist who made tons of errors???
From the Modern Medicine piece (I’ve added a link in the post):
Worker accountability… if we could ensure perfect patient care by hanging “be careful” signs and just asking for accountability, healthcare quality problems would have been solved ages ago. What I’m saying here is backed by the patient safety experts… and it happens to be compatible with the Lean philosophy that you have to create systems that make it difficult or impossible for errors to occur, that’s management’s responsibility, as Deming taught. Sorry that I actually believe that…
Quality improvement and culture is absolutely a lean topic… if you want to talk about 5S and lean tools, then there’s probably another blog for that.
From this news story:
http://blog.cleveland.com/metro/2009/05/expharmacist_eric_cropp_found.html
Ironically, the person who actually MADE the mistake was not charged or convicted of anything:
Dudash couldn’t explain why she MIXED a bag instead of using one off the shelf:
Here’s another systemic aspect of the problem:
Is anyone “held accountable” for that?
From the USA TODAY story:
It’s possible for the tech to have time to screw around on the internet while the pharmacist is overwhelmed with phone calls and requests and other tasks. Should Cropp have not “shrugged it off”? Probably. But again, if you want to just blame him, I don’t think JAIL was the right answer.
I don’t understand the logic of the pharmacist going to jail. The person who violated process and created the error gets off scot free, but the supervising pharmacist is “held accountable.” Why not hold the pharmacist’s manager accountable then?? It’s a shame there wasn’t more focus on process… just blame after the fact.
There are numerous examples of this, from Quaids children and baxters to the three neo-nates at methodists in Indy that died (query hospital, may have been somewhere else) as a result of a tech putting heperin in a hep-lock container (1000 fold difference in dose I think). In the latter incident no tech was disciplined as far as I know as the investigation found the processes and systems in the organisation wanting.
The classic example though is Vincristine (spelling?). Having had a number of deaths (its always fatal if administered inappropriately as I understand it) changes in organisations processes were undertaken in the UK.
It could only be signed out and administered by a specific group of people, it had a delivery method that ensured additional checks were made and this it was hoped would prevent a death.
A clincian ignored the processes and procedures, did their own thing, and subsequently was prosecuted and disciplined as far as a I know.
I do not think that additionals can be held responsible IF the processes and systems within an organisation are inadequate for the tasks being expected of them.
IF on the other hand every effort has been made to ensure that there are processes and checks and balances in place to ensure that no harm occurs and then an individual circumvents said systems, well, then IMO prosecution seems reasonable.
Andrew – Yes, it was Indianapolis where the 3 babies died. I wrote about it here: http://lnbg.us/18U
More from my blog on the Quaid case: http://lnbg.us/18S
One other thought – Cropp has to, as part of his probation, go to hospitals and talk about patient safety.
Will his message be “be careful” or something more effective in terms of improving systems? Will be warning pharmacists or talking with executives who can do more to influence culture?
should have said clincians not “additionals”, don’t know what that was about.
I’m working with one person that worked in Indy at that organisation and another who worked with Pronovost.
I think its difficult to hold people to account when corporately there are few processes and little support but if those systems are in place and there is a flagrant breach then I think those individuals are fair game for the courts.
Mark,
I am stuck with what appears to be a contradictory position on this topic.
You indicate that one should not blame the certified pharmacist who is bound by that certification to a high level of responsibility for the outcome, but then you suggest that one should blame the CEO for not being a ‘cheerleader’ for Lean processes?
I would prefer to see the tech ‘walking the line’ for having allowed themselves to become distracted during work, not being aware of the distraction and not understanding he safety-critical nature of the work at hand.
Of course, we have an entire generation of people now who operate in a semi-present mode; happy to walk mindlessly down the sidewalk starting at their hands waiting for a text message or tweet to come their way.
You’ve raised a call to arms for more power and independence at the worker level. Now, let’s apply the accountability where it is due.
.-= Jefferson Martin/synfluent ´s last blog ..Midvale Steel: Early Silicon Valley? =-.
My suggestion to jail CEOs was somewhat tongue-in-cheek. Simple blame (punishment) after the fact does no good, or little good.
Quality starts at the top. The CEOs and hospital executives need to start living that and not make it just empty words that quality and patient safety are the top priority. CEOs and other senior leaders have more of a responsibility for the system than the front-line workers do. That doesn’t mean workers can do just anything and not be held accountable. As Andrew is saying, there’s a difference between CHOOSING to not follow a policy (as the tech did) and the Pharmacist missing a defect through faulty inspection (a “slip” as the patient safety movement would call that, I believe).
If the Tech had time to wedding plan, she should had time to do her work properly. Then again, who is supervising here? Training her? Certifying that she was competent to do her job and not just the proverbial “warm body” filling a job?
If there are hospital execs reading this, I’d challenge you (in a friendly way) — what problem or possible quality problem did you help discover or fix today in a proactive manner??
I had an interesting conversation recently. Many leaders said it is a performance managment issue if a worker does not follow standard work. I challenged them that you still do not blame the individual but look at the failure of the management system that allowed the worker to not follow it.
Management may overburden people to the point where they can’t follow it via understaffing or asking for more than they can handle.
Management might not have observed the standard work in the workplace to see if it is feasible or requires additional improvement. They should have asked why the worker can’t follow and help correct.
If the worker is refusing and willfully violating, the mangement is responsible for knowing this is happening and taking action (maybe performance management at this point). In Lean, leaders can not take a “set it and forget it” attitude.
The pharmacist should not have been sent to jail. The leaders should have a better grasp on what is happening every day.
.-= Brian Buck ´s last blog ..Waste Of Breath: Wording Pet Peeves =-.
Mark: Bravo to you. Your impassioned commentary deserves applause. Only thing I can add is that there is at least one other system at fault here which needs to be redesigned, and that is the judicial system which imprisoned Cropp. [Something to reflect on: who is the CEO of that judicial system?] It is treating Cropp as a special cause (which it is designed to find) by assigning blame instead of recognizing a stable system of common causes needing systemic improvement; this is of course what Deming called tampering, and as you point out, it will likely make things worse. Who then will be blameworthy for the future deaths that result from the fear created by the actions taken against Cropp and the failure to act now to prevent future recurrences? Understanding variation and the proper strategies to use to reduce it is more critical than most people realize; misunderstanding it can destroy lives and careers (performance appraisals do this all the time in a more insidious fashion). How many even understand that reducing errors is but a specific form of reducing variation? Distinguishing between assignable (special) causes of errors and common causes is vital if genuine improvement is to occur.
A root cause of all of this is probably our culture of blame. Someone must always be found to be at fault and punished when errors occur. As a society, we don’t understand systems and systems thinking, or variation, or the need for a theory of knowledge than can be applied to social issues. In fact, I’d wager most people, if they read this, would probably say, “What the hell is he talking about?” And some who do understand it would say, “He’s a wacky liberal who doesn’t understand individual responsibility.” Well, I do understand it, and I will do everything I can as a responsible individual to help educate others so that our culture doesn’t continue to commit such further acts of disrespect to humanity as those reported in this sad story.
Thanks, Simon. It’s funny how I could be accused of being a class warfare warrior or a wacky liberal as a result of my commentary, when neither of those is the slightest bit true (no offense meant to wacky liberals).
As you’d agree with, I’m guessing, I’m all FOR personal accountability, but over the things we can truly be accountable for.
It’s so appealing, but overly simplistic, to follow this tempting line of thought:
1) Something horrible happened (Emily died)
2) It must be an individual’s fault
3) Punish that individual
4) Scream loudly about how that person has been caught and punished and this problem won’t happen again
If a person chooses to shoot a person on the street and steals their wallet, I’m far less interested in “systemic causes” of that situation (poverty, etc.). A workplace is different and there were clearly a number of things really broken in that hospital, it’s completely unfair to hold Cropp “accountable.”
He’s out of jail now, by the way.
Thanks to my pal Jay Parkinson for posting this.
http://blog.jayparkinsonmd.com/post/439057169/a-pharmacists-jail-cell-interview-what-good-does
One comment via someone who re-posted from his blog:
http://themagnificentang.tumblr.com/
This blog is great — it even hides low-rated comments (such as my initial one above) from everyone so as to not bother them. A bit like hiding data that does not entirely agree with a man-caused global warming situation.
If the comment on CEO-bashing was tongue-in-cheek, it was not so obvious. Maybe you should remove that paragraph because it takes away from the central theme of the article of not blaming people.
Do you think Apple Computer is such a great company because Steve Jobs “respects people” and “listens to them” and “works together”? Same thing with Bill Gates and Steve Ballmer. As far as I can tell, they are all 3 of them are very confrontational, listen to themselves, and ensure their people are not overworked? I agree that people should be treated with respect. I think it is good to listen to people (but not always to go with a consensus nor even a majority). And, working together has its merits. As does working apart.
Do you see the contradictory logic of:
1. CEOs should empower employees and let them fix things.
2. CEOs should be 100% responsible if the people they empowered do not fix things.
WWII Germany was not evil solely because of Hitler. Nor is Apple Computer successful solely because of Steve Jobs. The team wins or loses together. The polarization of “management” and “employees” is preventing lean from being successful. Maybe a new type of relationship is required. Customers and vendors?
Fred – Sorry about the comment being hidden. That’s literally the first time that’s happened in the 3 months that I’ve been this blog platform. My intent isn’t to have a club of people who all agree with each other. I’m trying to figure out how to change that.
I don’t think I’m “CEO bashing.” If you read what I wrote again, I asked a question — does the CEO ever get held accountable? I’m not saying anyone should be jailed in this example.
I don’t think the CEO is “100% responsible,” but we disagree. In a lean management system, it’s not contradictory that employees are empowered yet management is still responsible. Lean isn’t a traditional “top down” model nor is it completely “bottom up” where the top leaders abdicate responsibility.
Thanks for your opinion. I have no idea why you would bring up Hitler and Nazi Germany.
Apple and Microsoft are not followers of the lean management system. Jobs and Ballmer can act however they like.
Also, I can’t be blamed for creating management/employee polarization. It’s been around a very long time. In lean environments, we bridge that gap. I don’t want things to be combative. We need to work together.
As an owner of a few businesses, I can state with certitude that employees in my organizations are not going to be empowered to do anything over and above their job descriptions.
It is upon me solely as the owner to insure that the roles and responsibilities within those job descriptions are quite explicit and that we have designed, documented and trained the employee in those particular Use Cases and processes to achieve our goals.
I am confused as to how ‘Lean’ is neither top down nor bottom up.
I have an affinity to the top down style. I own the business; it’s my money; it’s my vision; it’s my goal, and try to excite others with the scenario that they, too, could rise up, be creative and spin-off a company that comes back to eat my lunch at what we do.
That sounds a lot like the Silicon Valley business model and it seems to work.
Polarization is what supplies the energy to the system. A little bit goes a long way.
.-= Jefferson Martin/synfluent ´s last blog ..Midvale Steel: Early Silicon Valley? =-.
[…] A Pharmacist’s Jail Cell Interview – What Good Does Blame Do? […]
Whether we are talking CEO’s or workers on a line or Pharmacists and Technicians – how does blame prevent future issues. LEAN is about continuous improvement and respect for people. Just placing blame goes against both of these ideals. Is it horrible that someone died because of a process issue/human error?? Very much so. Is punishment necessary?? Maybe. I’m no judge. I am more concerned about preventing it in the future.
We can play the blame game as much as we want but in the end the real questions/discussions need to surround process improvements – driven from the top AND the bottom. How can the CEO’s and management help prevent this from happening AGAIN? What ideas thoughts do the process experts (in this case the technicians and the pharmacists) have to improve the process?
@Jefferson Martin – It is sad to hear that you don’t believe your workers can become empowered. I know it is difficult to do, but I have worked to implement LEAN thinking in manufacturing and once colleagues realized that their ideas/thoughts were going to be taken seriously and action items were created to make THEIR jobs easier, many people were “empowered” to look for Continuous Improvement ideas on a regular basis. The key is (in my opinion) management coaching, support, and follow-up. It is that respect for people principle that makes the difference in really achieving improvment.
“We need to work together.” – Couldn’t agree more…
[…] Quaid says “medical error should not be criminalized. All it’s going to do is alienate the very people we’re trying to bring in to help.” I AGREE! […]
We are all missing the most important issue here. WHY ARE WE ALLOW A TECHNICIAN INSTEAD OF A PHARMACIST TO COMPOUND DRUG??!!!! IT SHOULD BE AGAINST THE LAW FOR ANY NON LICENSED PHARMACIST TO COMPOUND DRUG..ESPECIALLY IV..FOR PATIENTS. I am a 15 years licensed pharmacist working in the hospital. I always felt very angry whenever they rotate me to go work in the IV room instead of outpatient clinic. They hired one pharmacist and 3 technicians and that one pharmacist are responsible in checking the work of the technicians. How am I going to check??? The technicians can put 2 banana juice into the iv bag and I wouldn’t be able to check. I can only check the bag visually and rely on the technician being competent enough to inject the right thing and right amount…which he claimed…into the bag. IT IS SO SCARY!!!!! The technician is not responsible..only I am responsible because I supposed to be CHECKING..a licensed pharmacist. And I am as a pharmacist are not suppose to compound any drug because THERE IS NO TIME!!! IT IS SO BUSY IN THE PHARMACY…SIX HUNDRED ORDERS..AND NON STOP PHONE CALLS FROM THREE PHONES INQUIRING PHARMACIST FOR DRUG INFORMATIONS…THAT IS WHY THE HOSPITAL HIRED 3 TECHS TO HELP ME. I AM SUPPOSE TO CHECK THEIR WORK.
I think the US government and management of the health care should be sued for running our healtcare system like this. They want to spend less money cutting cost on hiring staff. Replacing pharmacist with non licensed people called technicians. A licensed technician is not equal to a licensed pharmacist.
This is what our government is doing.
Mina – thanks for your comment. I’m really sorry to hear that you’re in such a stressful situation at your hospital. It does sound scary… I’ve read horror stories about retail pharmacies have techs doing (or even have untrained stockpeople doing when it’s too busy)… that sort of bad management has to stop.
https://www.leanblog.org/2007/04/say-no-to-bad-drug-stores/
In Australia we have too much medico- and pharmaco-fraud so there certainly are doctors and pharmacists who should be in jail. But certainly agree they should not be there for making mistakes of process.
Having fee-for-service payments from government direct to providers is putting temptation in the way of too many people.
We hear cases of gamblers stealing from the government because they’ve lost too much, doctors and pharmacists self-administering drugs of addiction or habit, buying holiday houses and yachts, and let’s not start on the dubious ‘conferences’ and other lurks and perks.
I’d sooner see government payments made direct to the beneficiary, with vouchers or other mechanisms from the beneficiary to the practitioner.
[…] in healthcare, there’s still a tendency to wrongly look for “the idiot.” We often throw people in jail or ruin their careers. This approach probably does little to improve quality. In fact, the punitive […]
[…] medical error that occurred under their watch? Front line staff get fired all the time (or even jailed) — but again, I don’t think that’s the […]
[…] Relying on 100% human visual inspection doesn’t work because, well, we’re human. We get bored, we get distracted, and our brains often see what we expect to see rather than the actual signals that are sent from our eyes. Visual inspection often fails whether it’s Toyota workers inspecting the paint on a new truck or a pharmacist double checking a medication. […]
[…] Read my blog post about how the pharmacist was punished and JAILED. Chris doesn’t think that was the right response. […]
A new story looking back at what happened:
Eric Cropp Discusses Medical Error That Sent Him to Prison