Emily’s Law for Regulating Pharmacy Technicians Signed by Ohio Governor--Emily died as result of compounded drug medication error

COLUMBUS, Ohio, Jan. 7 /PRNewswire/ — SB 203, known as Emily’s Law, has received Governor Ted Strickland’s signature today, making the law official in the state of Ohio. Named after Emily Jerry, Emily’s Law will provide strict requirements and regulations for pharmacy technicians. The law, which was originally sponsored by Senator Tim Grendell, was drafted with assistance of the National Pharmacy Technician Association.

Emily’s Story
Emily Jerry died at the age of two as the result of a medication error caused by a pharmacy technician. On the day that Emily was to have her final chemo treatment and received an excellent prognosis from physicians, she was given a fatal dosage of chemotherapy. The pharmacy technician who prepared Emily’s chemotherapy had opted to compound her own normal saline base solution, as opposed to using a commercially manufactured (prepacked) IV solution bag.

Standard IV bags contain a base solution of 0.9% NaCL (sodium chloride); the base solution prepared for Emily contained approximately 20x the standard concentration of sodium chloride. Prior to entering a coma, Emily grabbed her head, screamed and cried as she experienced a fatal overdose of sodium chloride.

Although pharmacy technicians practice under the supervision of a licensed pharmacist, the public assumes that these individuals are still required to be properly trained and demonstrate competency to work within a pharmacy setting. While controversy still remains over the specific circumstances of what occurred that day in the pharmacy, the fact remains that a major medication error occurred, went uncaught and ultimately cost Emily Jerry her life. In the aftermath, local and national media attention exposed the gross inadequacies of pharmacy technician standards and regulations in Ohio (as well as across most of the United States).


Read more at http://www.redorbit.com/news/health/1619505/emilys_law_for_regulating_pharmacy_technicians_signed_by_ohio_governor/#vHzmjCVyuBslVQpZ.99

Criminalization of Medication Errors; Mistakes by Pharmacists

The following article appears at http://www.uspharmacist.com/content/c/16572/

Jesse C. Vivian, BS Pharm, JD

Professor, Department of Pharmacy Practice
College of Pharmacy and Health Sciences
Wayne State University
Detroit, Michigan

11/19/2009

US Pharm. 2009;34(11):66-68. Here is a sobering thought. A pharmacist makes a mistake. The error results in the death of a patient, and the pharmacist is charged with negligent homicide. He is found guilty of involuntary manslaughter and faces up to 5 years in prison and a maximum fine of $10,000. Of course, his pharmacist license is revoked and chances are he will never work in the profession again. His crime? He did not check the accuracy of calculations used by a pharmacy technician under his charge to compound the concentration of sodium chloride in a prescription for a cancer chemotherapy solution.
Negligent? Yes. Accountability and responsibility? Yes and Yes. Malpractice? Yes. Loss of license? Yes. Guilty? Yes. But a crime? Prison term? For a mistake, albeit a mistake with a worst-case outcome? That is tough medicine to swallow. More important, how is justice served by putting this pharmacist in jail? The message to pharmacists and perhaps all other health care practitioners—watch out. There may be prosecutors out there just itching to put you away.

Facts of the Case

On February 24, 2006, while working at the Rainbow Babies and Children’s Hospital in Cleveland, Ohio, licensed pharmacist Eric Cropp received a prescription for a chemotherapy solution of Eposin (etoposide phosphate) that was supposed to be mixed in an IV bag of normal saline containing 0.9%