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Fatal dose: Pharmacy tech working again

Channel 3 News has learned that Pharmacy Technician Katie Ferg-Dudash, who mixed a fatal dose of Sodium Chloride that killed 2-year-old Emily Jerry is working at a local CVS Pharmacy.

In February 2006, Emily Jerry went to Rainbow Babies and Children’s Hospital for her final dose of chemotherapy for a cancerous tumor in her abdomen. By this point, it appeared Emily had beaten the cancer but her doctors wanted her to have one more dose to make sure.

On February 26, 2006, records show Katie Ferg- Dudash was working in the IV room where chemo drugs are compounded. Records show Dudash mixed a dose of Sodium Chloride that was 24 times more than the prescribed amount. She informed supervising pharmacist, Eric Cropp, that she thought something was wrong with the mixture but neither of them stopped the dose from reaching Emily.

Emily Jerry died from the overdose on March 1st.

Now Dudash is working as a Pharmacy Technician at the Euclid CVS at E. 222nd and Lakeshore. Channel 3 was unable to reach her for comment.

CVS Corporate claims in a statement, “Prior to her employment at the hospital, Dudash worked at the Euclid location for several years as a Pharmacy Technician and had an excellent record. We were not aware of the incident at the hospital until today, in which it is our understanding there were no criminal charges filed. CVS does not allow technicians to compound medications. We have placed Katie on paid leave while we investigate this matter further.”

Last month, Cropp went before the Ohio Pharmacy Board and was stripped of his Pharmacist license. Pharmacists are held ultimately responsible for any mistake made by a Pharmacy Technician.

There are no laws in Ohio regulating the Pharmacy Technician field. So Dudash is not breaking any law, was never criminally charged and is free to continue in her field. That’s why State Senator Tim Grendell and Rep. Steve LaTourette are drafting state and federal legislation to regulate the Pharmacy Technician field. Ohio is one of a handful of states that require no certification, licensing, testing or training requirements.

Article written by Monica Robins, for WKYC.com. It was originally posted
on 5/9/2007.

12 Comments on “Fatal dose: Pharmacy tech working again

  1. Really Sad, I do not think that the Pharmacy Technician should be working in the health care industry. I think the Pharm Tech should have been jailed, not the pharmacist, because it was the Pharm Tech who mixed it, and brought it out admitting she had doubts about it.

  2. The laws have changed dramatically since this article. Technicians now must be certified before working in a hospital pharmacy. Ohio will soon be a leader in the pharmacy field as the Pharmacy Practice Model Initiative will require even more education for pharmacy technicians and possibly even state licensure. Emily’s tragedy is resulting in a dramatic positive for the pharmacy in this state and nationally.

  3. I personally think that a pharmacy technician (most pharmacy techs just have a High School diploma) with the marginal education they have SHOUL NOT BE preparing IV admixtures in any healthcare “organization”. I make a point in the word “organization” since it is how we call a company or corporation. There is nothing “organized” regarding allowing a marginally educated person do the job that the pharmacist (5 to 6 years of college pharmacist) with a PharmD degree is trained to do, even after the 6 years of college education. In the case of the pharmacy technician, they have no education at all, and allowed to do professional work that requires pharmaceutical knowledge and 6 years of pharmacy school is a crime from all points of view. It is the same as the physician neurosurgeon allowing the “housekeeping” lady that cleans the operating room floors, do surgeries for his brain surgery patients, just because she is a “cheaper employee”. The physician allows the PA touch his patients records, and evaluate his patients, but at least the PA do not have a marginally educated high school education. The PA at least need to have a Master degree in medical sciences, and a license, and pass a board. The justification in allowing the pharmacy tech do high technology pharmacy practice is pure greed, and of course money. That is the reason why the hospital pharmacy and the hospital administration allowed this ” uneducated and un-trained idiot” do the IV admixtures for the pediatric chemo patients. She is working for CVS, of course, CVS is the largest producer of pharmacy errors in the nation. She is now working where she should be at. However, she is not mixing pediatric chemo IV bags any longer. She already killed (murdered) a child!

    • Very well said!! I couldn’t agree with you more!! This chic is DEFINITELY an idiot and she’s lucky it wasn’t my child! I feel terrible for this family and HOW does ANYONE mistake 1% for almost 24%?! It’s unbelievable really. I believe I learned that in elementary school and this chic is working in an IV hood compounding her own solution when there were bags already made?! I want to know WHY SHE didn’t get ANY punishment and only the pharmacist took the fall?! I understand it’s their bottom line, ultimately, BUT she really should have known better because a 5th grader could have figured it out!! So, I guess she’s NOT smarter than a 5th grader!! Idiot us precisely correct!!

    • I never knew such little was required to become a pharm tech. That is just insane if you think about it you need school and certification to do hair or nails. To even become a realtor you need to pass a state test. That’s just crazy…

    • With proper training and education pharmacy technicians are often better and have much better sterile techniques than the pharmacists do when it comes to compounding IVs. Thank you for insulting an entire profession with your lack of knowledge.

  4. This is a mistake that led to a tragedy. I’m sure both the Pharmacist and Technician, will be haunted forever by this mistake. But who can sit here and say they’ve never made a mistake at their job? Even with extreme focus and expertise, mistakes still happen… And it is ultimately the Pharmacist’s responsibility to check all medications before they go out to patients, through visual verification. I think a tech’s job should be limited to mainly just counting pills, as they do at CVS!!! Not mixing solution injections for hospital patients…

    • There should be shared liability..Both pharmacist and tech should be held responsible for any error..The tech has an obligation to follow procedures and should not depend on the pharmacist to correct them..

    • @Randy — While preparing Emily’s last dose of IV chemotherapy, the drug was diluted in a IV bag containing concentrated sodium chloride (NaCl 23.4%) instead of the standard (“normal saline”) concentration of sodium chloride (NaCl 0.9%).

  5. How in the world that the hospital was not found responsible is unbelievable. The hospital knowingly understaffed the weekend and had the pharmacist working double shifts. The accidental overdose was made up on a Sunday after the doctor entered digital records were DOWN for hours due to computer maintenance. This means NO WRITTEN RECORDS produced for hours. When system came up, hours of medical input printed. Chaos will occur and some safety measures may fail when someone who’d worked doubleshifts two days in a row prior with no breaks tries to rush late orders. The tech compounded the wrong saline solution, the 26x amount of salt caused immediate swelling of Emily’s brain.
    This was not just the tech’s fault, nor the pharmacist’s (whose life was ruined). The hospital ultimately was responsible for not having adequate staff and for not making specific plans for when computer was down.

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