Abstract
A lethal error in making injectable colchicine has resulted in federal criminal charges against a Texas pharmacy and its pharmacist-in-charge. The error, according to an early public statement by the pharmacist-in-charge, was a “breach in protocol” that “apparently resulted in the batch being more potent than was indicated on the label.” The deaths occurred in Oregon and Washington, several states away from the pharmacy where the colchicine injection had been made. Criminalization of an error in health care? In January, the National Coordinating Council for Medication Error Reporting and Prevention revised its eight-month-old position statement opposing the criminalization of errors in health care. The revision gives more prominence to the sentence “Criminal acts and patient harm related to competency and/or licensure issues are not addressed in this statement as they are beyond the Council’s purview.” As to the criminal case in Texas, Council Chair Manisha Shah in an e-mail said the role of the group does not include commenting on individual events.
Published Version
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