Thursday, February 18, 2010

Pharmacist Released From Jail

Jailed Pharmacist is Released

A pharmacist has been released from jail because he was involved in the death of a little girl given a wrong dose of chemotherapy mixture.

Medical professionals involved with patient safety are celebrating his release but saddened that he was actually jailed. Patients and families who have lived this sort of medical error experience are celebrating his arrest, conviction and sentence.

I have mixed emotions. I can comment because I have lived it. My son was killed by a physician who allowed him to bleed to death following his tonsillectomy. Did I want him jailed? Sure, maybe jail was even too good. Did I believe jail would have helped? Probably not.

It’s not unlike hitting the dog when he messes in the house. It gives us a sense of satisfaction and release of tension but it solves nothing. This pharmacist, I believe is not a criminal, he was careless but not a criminal. He did not belong in jail. Human error will not stop because a man was jailed because of an error. Systems won’t change because of this experience. He was the dog that was hit, but, by not finding out why the dog messed in the house, it will just continue and create an angry dog.

I had a recent conversation with a hospital administrator about how people with disabilities are handled at his facility. He said that staff is taught to take extra time, be available and be careful. “But” I asked him, “Are you willing to take patients away from the nurse who has a disabled patient so she can actually spend more time caring for this patient or, do you just tell the nurse to be more careful?”

He agreed that his hospital was not lightening the load, just going through the words. So when a disabled patient falls or is injured, will the nurse be “blamed?” Hospital administrators know where the problems are. They sometimes need to address them from the “grassroots” level (see yesterdays posting).

Chances are the hospital administration knew that there was trouble in the pharmacy at that Cleveland hospital but by allowing it to continue a little girl died. If they didn’t know there was a problem, shame again that no one told them. Either way, a little girl is dead and a pharmacist will never work as a pharmacist again. No one wins – will anything change?

You can read more details about the case here from the Institute for Safe Medication Practices.