Shadow of the law in cases of avoidable harm

“Jail time for a medical error.” This was the headline of Bob Wachter’s patient safety blog about the Ohio pharmacist Eric Cropp.1 When Cropp’s professional colleagues saw him clad in an orange jumpsuit in a prison visiting room, they knew it could have been them. A pharmacy technician mistakenly mixed chemotherapy drugs with 23% saline, not 0.9%. A child died. It was a rushed, understaffed day, with computer failures. Cropp’s supervisory check failed to spot the error. He was convicted of manslaughter in 2009.

A junior doctor in Nottingham, England, was jailed in 2003 for killing a cancer patient who was given vincristine through the wrong route. The investigator had identified some 40 systems failures,2 yet individual accountability won the day in court. It had happened before in the UK in similar circumstances, but other doctors had been quietly counselled.

A look back from 2005 at the doctors charged with manslaughter in …