By guest blogger Michael Cohen:

All individuals are wired to make errors. Who among us hasn’t forgotten to turn off an iron or tried to pull rather than push a handle to open a door? Most of the time these faux pas are of no serious consequence, but very similar human errors due to forgetfulness occasionally do lead to harm.

The tragic death of a severely autistic young man, Bryan Nevins, is an example. No one doubts that leaving Nevins in the Woods Services van after returning from a Sesame Place outing on an extremely hot summer afternoon was completely unintentional. Yet Stacey Strauss, a residential counselor at the facility and driver of the car in which Nevins was later found dead, has been charged with involuntary manslaughter and, if convicted, faces a prison sentence (http://www.philly.com/dailynews/national/99902089.html).  Should human errors, which all of us are prone to, result in a jail term?

Healthcare practitioners have also been increasingly facing the fear of criminal prosecution for unintentional human errors that result in a patient’s death.  Last year Ohio pharmacist Eric Cropp was sentenced to 6 months in prison, 6 months of home confinement with electronic monitoring, 3 years of probation, 400 hours of community service, a $5,000 fine, and payment of court costs, for his role in a fatal medication error.

Like Strauss, Cropp came to work that day and expected to help not hurt. Instead, in error he overlooked a pharmacy technician’s mistake in preparing a critical IV drug for a 2-year-old child with cancer, Emily Jerry. It was also a tragic human error, and one that other pharmacists admitted could happen again, given the inherent weaknesses in many of America’s pharmacy systems. You can read more here: http://www.ismp.org/Newsletters/acutecare/articles/20091203.asp

I understand that people like Strauss and Cropp are in a position of responsibility, entrusted with the lives of others. Unfortunately though, human error sometimes trumps any level of responsibility. There are 100,000 deaths a year due to medical errors, and while it’s difficult to understand how you could leave someone in a car in summer heat, there are 30 to 40 heat related deaths of children left in cars every year. It’s happened to responsible people like grandfathers, doctors, lawyers, daycare workers, ministers and many others. They simply forgot the child was in the car and there was no system to help them not forget. 

I also understand there are times when behavior is reckless, such accidents that happen while drug impaired or while driving 120 miles an hour on a road with a 55 MPH limit. I completely agree that such instances deserve punishment. But neither seems to be the case with Cropp or Strauss.

Do we just tell drivers and pharmacists to be more careful or even punish them severely and leave it at that? Or are there higher level prevention strategies? Currently there are system enhancements and technologies available in hospitals such as the use of checklists, bar coding, and computer order entry, all of which can let us know when a mistake was made – before an injury occurs. Similarly, given the number of tragic deaths in cars, clearly it would be appropriate for automobile manufacturers to begin providing technology that sounds an alarm when the car doors are closed while the buckle of someone’s seatbelt is still fastened. Facilities such as Woods need to document roll calls before and after trips. And until such fail safe changes come, consider that when a small child is in the backseat you should place necessary items such as cell phone, pocketbook, or briefcase as a reminder to check the back seat of the car before exiting. Or their diaper bag in the front seat.

I completely understand the angst and the call for retribution by families left behind and I also recognize they need someone to blame and be accountable for the pain of their horrific loss.  I agree they do need to be told the truth about the cause of the error and must be financially compensated as quickly as possible, all of which could be accomplished through civil lawsuits. But, I do not concur that the incarceration of Strauss or Cropp will help alleviate someone else’s tragic human error from reoccurring.

We can continue to put people in prison for unintentional human error or we can work diligently to improve the systems in the U.S. by promoting safety initiatives, such as technology, better communication methods, appropriate staffing and educational levels of practitioners and a host of other safety initiatives.

We need to ask ourselves if it is rational to prosecute individuals who unintentionally harm another or, instead, put in place safety systems to make it impossible or at least unlikely that human errors will kill someone. I’d be interested in your thoughts.

For information on the Institute for Safe Medication Practices' consumer website go www.consumermedsafety.org
 
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