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The greatest injustice in hospital pharmacy history and ASHP’s cowardly and disgraceful response

04/17/2010

Warning:  This post is not about informatics.  It is about the greatest injustice in hospital pharmacy history and the organization that represents that profession.  Numerous facts and details of this injustice can found in the links below and in some of my other writings.

First, here is my perspective.  I have been a hospital pharmacist in one capacity or another for 30 years that has made and presided over, as a manager, many medication errors.  Some that have caused horrible harm and suffering.  I am active and have been elected to leadership positions in many professional organizations including the one I will criticize here, the American Association of Health System Pharmacists (ASHP).

The stellar, admirable and heartfelt response to this case by Michael Cohen and the Institute for Safe Medication Practices (ISMP) is an example of a commitment to a principle, regardless of how it looks or the consequences (links below). 

ASHP calls itself a membership organization.  It seems to me they should support their constituency in the darks hours of injustice.  A membership organization should rise up and defend their constituency against injustices, the way Nursing organizations have done recently.

ISMP’s and Nursing member organization responses to injustice is strikingly different than the repulsive ‘head in the sand’ approach by ASHP.

When this error occurred and criminal prosecution went forward, I contact the President and two board members of ASHP inquiring on what the organizations response will be.  They indicated that they would response quickly to this injustice.  There was no response and nothing happen for almost a year.  It was not until I submitted a letter to their official journal, AJHP, asking for action, that the response came.  [Link to ASHP Response]

The ASHP response to the Eric Cropp case contains a cowardly mischaracterization about the case.  Dr. Thompson indicates that ASHP “does not and will not have access to all of the facts” therefore will not comment. The facts of the case are very public and available in the form of court and pharmacy board transcripts, numerous news articles, attorney commentary, interviews of Eric Cropp, route cause analysis and very detailed webinar by ISMP (see below).   Why ASHP would not seek out these facts is beyond belief. 

Insinuated here and others have secretly whispered to me that “oh, you do not know all of the facts of the case, if you did you would not feel the way you do”.  To me, that is someone wanting to feel superior and justify the mob mentality that took over in this case.  I have also gotten numerous communications on this case in support my views; that this case really was a system error.  With so much public information this whispering behind the curtain is not valid on either side of the case.  A membership organization should have the spine to make a call on the public information or even get up from the desk and do a little leg work to find out informations that maybe lacking.

Additionally what I get from the Dr. Thompson’s response is that ASHP is committed to and has done many organizational and policy things in the name of patient safety and Just Culture.  These are commendable.   It is the lack of putting these think tank policy actions into actions that I find disgraceful.

Using the facts of the case and applying the basic principles of Just Culture brings you to the clear conclusion of a gross miscarriage of justice.  Even the father of the dead infant came to this inevitable conclusion.  It is surprising for a professional organization not to seek out these readily available facts and apply the principles they supposedly hold so dearly in this individual case. 

Not seeking the readily available facts of the case draws me to the conclusion that while ASHP works on a high level policy, but when it comes to individuals, where these policies have a real impact, they hide behind a cowardly veil of “facts not available”.   

The fact that ASHP focuses on organizational initiatives but fails to act on an individual case of a hospital pharmacist injustice is what strikes me as weak, noncommittal and disgraceful for a hospital pharmacy membership association.

Lucian Leape, in testimony before Congress on health care quality improvement stated “The single greatest impediment to error prevention in the medical industry is that we punish people for making mistakes.”  ASHP’s complete lack of action and turning a blind eye to Eric Cropp will set us back years.

What say you?

Background and Reference Links

Wachter's World by noted Hospitalist Bob Wachter: Jail Time for Medical Error, Redux

http://www.ismp.org/pressroom/Judge_Corrigan_07-13-09.pdf 
http://www.ismp.org/Newsletters/acutecare/articles/20090827.asp 
http://www.ismp.org/Newsletters/acutecare/articles/20091203.asp 
http://bit.ly/cqsy76 (Webinar Replay)

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