Doctors Confess Their Fatal Mistakes

Doctors, nurses, and pharmacists hold your life in their hands. Here, their shocking stories of what can go wrong—and what has to improve to keep us safe.

By Joe Kita from Reader's Digest | October 2010

“The Wrong Medication Dose Killed a Toddler”
By Eric Cropp

It was a busy Sunday in the pharmacy at Rainbow Babies & Children’s Hospital in Cleveland. The hospital’s computer system had been down for about ten hours before I started my shift, and because I was teamed with a pharmacist who was fairly new to the department, I had additional responsibility. But I’d been in busy situations many times before. In fact, I had 14 years of experience and had been president of the Northern Ohio Academy of Pharmacy.

But on this day, I made the mistake of not thoroughly checking a saline-solution base that a technician had prepared for a child’s chemotherapy treatment. She mixed it more than 20 times stronger than ordered, and I didn’t catch it. When a nurse administered it, the high concentration of the sodium chloride flowing through the child’s veins made her brain swell and put her in a coma. Three days later, she died. Her name was Emily, and she was two years old.

I was eventually convicted of involuntary manslaughter, for which I received six months of jail time, six months of house arrest, three years of probation, a $5,000 fine, and 400 hours of community service. I also lost my license, career, reputation, and confidence. But most devastating of all is that I have to live every day with the memory of that little girl.

I accept full responsibility for what happened. I should have checked the solution more carefully. But there are some facets of hospital and retail pharmaceutical work that desperately need fixing if similar tragedies are to be avoided.

How to Fix the Problem

Pharmacy technicians need better training. Most people don’t realize that techs have something to do with approximately 96 percent of prescriptions dispensed in pharmacies, according to the National Pharmacy Technician Association (NPTA). Yet 92 percent of us live in states that do not require them to have any formal training. (The tech in my case had a high school diploma.) Ohio recently adopted Emily’s Law, which requires that all techs undergo training and pass a competency exam. The NPTA is currently working on a bill that would institute Emily’s Law nationwide.

We should also take advantage of technology. There are lots of look-alike, sound-alike medications that come in small vials with tiny labels. A bar-code scanning system, like the ones in supermarkets, would supply an extra layer of safety.

But technology isn’t enough; pharmacists and techs need better working conditions. Pharmacies can be cramped and the workload is often heavy. But studies suggest that crowding and dim lighting make mistakes more likely. So do interruptions, and the need to fill too many prescriptions. Believe me, a lot of pharmacists say a little prayer on their way home that an error didn’t slip through.

Finally, I wonder what would have happened if I had talked Emily’s family right away and said I was sorry. I was advised against doing that. That’s the way it is in the medical world when a mistake occurs: Hospital management may meet with the family, but the health care worker is often advised not to make a personal apology. Too much of a culture of silence still exists and must change. Doctors, nurses, pharmacists, and others need to be able to come together to confess their mistakes, clear their consciences, be supported, and, most important, work together to make the system safer.

Eric Cropp, 42, is currently unemployed

  • Your Comments

    • Happy Place

      I like a National Healthcare System

    • http://www.facebook.com/people/Rod-Venger/747469101 Rod Venger

      These doctors are horrible and their confessions do not absolve them of anything. I pity the pharmacist that took the fall or his tech’s error, but he was the supervisor…as for the nurse, God protect us from nurse-managers. No person can be intimidated or threatened unless they allow themselves to be. Nurses are like wolves, pack animals looking to protect each other from outside forces. The alpha nurse, the manager, like all others before her, used to be just a normal, hard working nurse. Once tapped for management, they lose all their humanity, working not for the good of the patient but for the good of the system. No surprise that this one lines up with a union. The pack can never be wrong nor accused of being wrong for they have all the fangs. That’s convenient when it comes to laying blame for someone’s untimely death.

    • Change is slow

      While I appreciate this article, there are many flaws in the system, just mentioned a tad in this article that could have books written on them, such as the intern system…the voices say it needs to change, but those who made it through perpetuate it. Right now it is nearly impossible to change. Or that Geisner systems improperly implemented give a physician incentive to hide the source of re-admission, and that going to another facility doesn’t mean the truth will come out, as doctors protect each other as a means of protecting themselves. Its a deep rooted complex topic, and those with advocates fare better in terms of protecting themselves from mistakes, but fare worse in terms of the backlash from the medical community, not just during their immediate care but any care related or not, afterwards.

    • CTG

      Obama Care is the best thing any President has ever put in place. Try getting insurance with pre-existing conditions – it is IMPOSSIBLE! You either get totaly denied coverage or they place riders and still charge prices so high you cannot afford the coverage. You need to do your research or try walking in someone elses shoes when you cannot get medical help!

    • CTG

      Obama Care is the best thing any President has ever put in place. Try getting insurance with pre-existing conditions – it is IMPOSSIBLE! You either get totaly denied coverage or they place riders and still charge prices so high you cannot afford the coverage. You need to do your research or try walking in someone elses shoes when you cannot get medical help!

    • Davekyguy

      Wait till Obamacare cuts the Dr.s pay and starts rationing care.

      They are going to save money all right, just like they did when they stole 500 billion from Medicare.

      • Bill

        Nonsense. Pure dittohead rubbish. You’re statement are wrong and taken just as fox misrepresented the,m.

        “Obamacare” rationing healthcare? You mean like the current HMO’s do? Why do you think this country is moving towards a nationalized healthcare system? Because of the corrupt insurance providers!

        Turn off fox and raise your IQ.