5.5.11 | Brandon Glenn

Ohio father behind ‘Emily’s Law’ to publicly forgive pharmacist

An Ohio father whose 2-year-old daughter’s 2006 death spurred the passage of “Emily’s Law” is preparing to publicly forgive the pharmacist who went to prison for a medical error that led to the death.

Chris Jerry, who has since started the Emily Jerry Foundation to raise awareness of medication errors, said he plans to forgive Eric Cropp in an interview next week for a segment on the Discovery Channel about patient safety.

“The criminalization of medical errors is an enormous setback for the patient-safety movement,” Jerry said.

“When these tragedies occur, instead of pointing fingers, we need to focus on what actually caused the event and what we can do to minimize this from happening in the future,” he continued. “Eric should never have gone to prison.”

Cropp, a former pharmacist at University Hospitals Rainbow Babies & Children’s Hospital, was convicted in August 2009 of involuntary manslaughter for approving in 2006 a pharmacy technician’s fatal saline solution for 2-year-old Emily, who was on her final phase of cancer treatment. The technician, Katie Dudash, prepared a chemotherapy mix for Emily that was 23 percent salt-based when it should have been only 1 percent.

The Jerry case sparked reform of pharmacy technician practices along with the prosecution of Cropp, who was stripped of his license in 2007 for his error and 15 subsequent unrelated errors. Ohio legislators in 2009 passed Emily’s Law, which created licensing and minimum education requirements for pharmacy technicians — a change largely cheered by educators and others in the local industry.

Pharmacy trade groups, though, called the prosecution inappropriate and unwarranted. They say cases like Cropp’s could make pharmacists less likely to report errors and slow systemic change, outcomes that are likely to prevent future tragedies.

Jerry seems to agree with that assessment. “Cropp and Dudash are part of the overall tragedy,” he said. “They’re really just victims of an ineffective patient-safety system.”

The problem with criminalizing medical errors, according to Jerry, is that, “People will be less likely to step up and say ‘I made the mistake’ in fear of criminal prosecution and being persecuted by the public.”

Among the foundation’s largest focuses is the passage of a federal equivalent of Emily’s Law. Jerry is looking for a member of Congress who’d be interested in sponsoring the legislation.

Additionally, the foundation is looking to bring attention to “partner” companies that sell technology that holds the potential to reduce medication errors. Those companies include chemical-detection firm CDEX and intravenous drug-delivery firm S.E.A. Medical Systems.

Eventually, Jerry hopes the foundation can sponsor clinical trials of patient-safety technology to help safety products reach the market faster. He envisions an “Emily Jerry Foundation Seal of Approval,” much like the well-known Good Housekeeping Seal.

Jerry’s interview in which he’ll forgive Cropp is for “Chasing Zero,” a Discovery Channel program on patient safety hosted by actor Dennis Quaid. The interview is scheduled for next week, but it’s unclear when the program will air.

Here’s an interview with Chris Jerry:

Brandon Glenn MedCity News

Brandon Glenn is the Ohio bureau chief for MedCity News.

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Tags: Emily Jerry, Eric Cropp, Ohio, Politics

Comments Post a comment

If Mr. Jerry truly thought the ciminalization of medication errors has set back the patient safety movement, he would abandon his push for a federal equivalent of Emily’s law. Mistakes happen, as unfortunate as they are, they happen. People die because of medcial errors. Does that mean that they should be vilafied and sent to prison. Definitely not. Does it mean that their livelihood should be taken away because of the one mistake. Also definitely not. Mr.Cropp made a terrible mistake. Not on purpose, but a mistake. He is only human. But now he is in prison and can’t practice pharmacy which took him a long time and effort to study and get his license. He needs to be able to suppport himself with the knowledge he has gained with his education and experience. He needs his license back.

Comment by Littlebones2 — May 10, 2011 @ 12:39 pm

Unfortunately medication errors are made by physicians, pharmacists, and nurses, all of whom are doing their best to serve and protect the patient. Without proper policies, procedures, and systems in place AND EVERYONE following them errors will occur even with the most dilgent double checking.
To criminalize medication errors serves no one and will ultimately severely reduce the number of errors reported. Only by reporting these errors can we learn from mistakes and systems failure and correct the root cause.
As tragic as the case was, to me it smacks of political ambition by an over-zealous prosecutor out for a conviction and publicity. How fair would be if he/ she made a mistake on a prosecution and was then charged with criminal deriliction of duty because a killer went free to kill again?

Comment by RPHTRE61 — May 10, 2011 @ 6:04 pm

We have got some interesting comments already. I think its important to note what Emily’s law does. I will be an Ohio pharmacist starting June 2011, so I am familiar with Emily’s Law.
What it DOESN’T do:
1. Criminalize medication errors
2. Impose additional requirements on pharmacists concerning their training/ continuing education.
What it DOES do (Full law: http://bit.ly/iRh5HR):
1. Require that pharmacy technicians:
a. Be at least 18 yrs old
b. Graduate high school or equivalent
c. Pass a test on law, pharmacy practice, math, pharmacy equipment etc.
d. Pass a criminal background check
2. Pharmacists must maintain records to prove that the law has been adhered to as described in #1.
a. Failure to adhere to the law has criminal penalties

Many pharmacy organizations are in favor of developing a fair (or just) way to punish pharmacists that are negligent or malacious in their actions, while finding solutions for errors that occur due to human error. Here is a summary of “just culture.” (http://bit.ly/mxQyGh).

When errors do occur it is important that they all are examined (not just those that have tragic consequences). When they do have tragic consequences it is important to console the family and the pharmacist. My impression is that part of the reason that Eric Cropp was jailed is because he made multiple errors after the tragedy. Those errors could have been avoided if: 1) he had taken a break for a while 2) he had grief counseling 3) he didn’t move from a hospital pharmacy to a retail pharmacy that has a very different work flow, kinds of medications, more distractions etc.

Inconsistency in work flow processes are recognized to cause errors. Do you think you’d press the brake in your car and not the gas if in some cars the brake was on the right and the gas were on the left? This a similar scenario when Eric was fired (maybe quit?) from the children’s hospital and then found work in a place like Walgreens–were he made 15 more errors.

Comment by David Kramp — May 11, 2011 @ 9:43 pm

Five years to figure out that criminalzation of medication errors is horribly misguided? What took Mr. Jerry so long? I think MRS. Jerry’s silence speaks volumes and illustrates how indescribable emotional pain can fuel a mob mentality, whether it be across spousal lines, in the courtroom, or via the media. Frankly, it’s amazing that so may pharmacy schools have popped up over the last few years given the outcome of this case.

Comment by Ill DOP — May 16, 2011 @ 4:24 pm

What happened to Emily is sad and unfortunate. But to criminalize people for the actions of one individual is insane. Emily’s Law should be repealed immediately and something else put in its place.
I am a 51 year old US Army Veteran with two Honorable discharges. I have a college degree and I am a upright citizen.
I am a Certified Pharmacy Tech and have been in the Pharmacy Tech field since 1994. I have also taught Pharmacy Tech at a local college and run my own Pharmacy Tech certification school. Many of my students have gotten certified and went on to become CPhT.
I have never been written up on the job and my work record is impeccable. Oh I forgot to mention when I was 18 I was convicted for receiving stolen property (a hotel key). Yes me and my buddy used to party in empty hotels rooms. Part of Emily’s law says that you can’t have any felony convictions. Why must I continue to be punished for something that I did as a child. I can’t get a job in the field that I love and do something that I am good at. I’m sure there are others out there like me. This law needs to be repealed.

Comment by Rob — July 13, 2011 @ 1:36 pm

I was a pharmacy tech for one year. Until that point, I had worked in accounting offices. I truly thought I had found something else to dedicate myself to, something that was truly important. That one year, however, opened my eyes to how ugly the Pharmacy field really is, and reading about what happened to Emily Jerry cinched it. I have since left the field and will never work in it again, unless I am working on the sidelines for a pharmaceutical company in the finance area. What I learned is:
1. The medical field is full of human beings who are capable of making mistakes. Unfortunately, those mistakes can be fatal to the patients, but they are not deliberate. The fact that this pharmacist was penalized so severely did indeed raise the possibility of errors not being reported and thus no steps taken to prevent them. I saw it happen in my pharmacy time and again. In the accounting field, however, when someone makes a non-fatal mistake and causes errors with a financial report, the mistake is corrected and documented, and the one who made the mistake takes steps to ensure that it never happens again and passes the knowledge on to others who did not know such a mistake could occur. Isn’t it sad how accounting professionals can take such steps in a field that has less liability and yet medical professionals do not?
2. Pharmacy techs are way more likely to take the blame than the pharmacist on duty when errors are made. When possible, the pharmacist will roll the tech under the bus to protect his or her own skin. Again, I saw many techs in my pharmacy lose their jobs because of mistakes that the pharmacist made. One of those techs, who was a good friend of mine, committed suicide.
3. Pharmacists spend 6 years becoming educated and licensed. Pharmacy techs spend up to 2 years getting educated and licensed, and yet they are the ones explaining to pharmacists how IV bags should be prepared. I lost count of how many errors I caught for the pharmacist, and yet I was paid 1/16th of the salary that the pharmacist was. Something wrong with this picture?

Hats off to you Mr. Jerry for publicly forgiving the pharmacist and tech for what happened to your daughter, but you are 5 years too late. While some good did indeed came from your crusade (I agree that techs should be educated and licensed and certified), it also paved the way for medical professionals to cover their rear ends if possible whenever an error occurs, even if it means costing an innocent person their job. I saw some patients die due to medical errors, and I saw how those errors were covered up. Bottom line: Keep the laws regarding education and licensure the way they currently are, pay the techs what they are worth, and do not penalize medical professionals for making human errors. Work together, learn from mistakes, and healthcare will once again be what it used to be.

Comment by Former CPhT — December 1, 2011 @ 1:51 pm