“Oh, the fine clothes, the handsome homes,
the watches, rings, pins that some boys sported; the dandies many youths of
his years already were! Some parents of boys of his years actually gave them
cars of their own to ride in. They were to be seen upon the principal streets
of Kansas City flitting to and fro like flies. And pretty girls with them.
And he had nothing. And he never had had.”
Theodore Dreiser
An American Tragedy, 1925
The parallels between disgraced pharmacist Robert Courtney and Clyde Griffiths,
the protagonist of Theodore Dreiser’s classic American novel, An American
Tragedy, are simply stunning.
The sons of poor, itinerant Midwestern preachers, both Courtney and the fictional
Griffiths find their way to Kansas City only to be seduced by the glitter
around them. In time, they each abandon God for Mammon and commit cold, soulless
sins of omission that lead—allegedly at least—to the death of innocents.
So classic is the motivation, and so accessible are the means, that one must
marvel that there have not been more Robert Courtneys. The present system,
in fact, can be abused about as easily as human nature can be corrupted.
Yet despite the potential depth of the scandal, responses to it have been
largely superficial and predictable. They tend also to focus on Courtney,
the person, and his presumably criminal deeds. The human drama of his undoing,
however, blinds the public to an even larger problem within the world of drug
distribution, namely medication error. The deaths from such errors far exceed
those from criminal mischief. According to Jerry Blair, product manager at
the Cerner Corporation, “they are equivalent to a 747 crashing every
week.”
These deaths, though dramatically more frequent, lack the capacity to shock
in the way Courtney’s alleged crimes do. If there is a silver lining
in the Courtney saga, it just might be that his misdeeds will force the public
and the medical establishment to take a good long look at the way it distributes
medication.
First a little background. For those who have been on an extended summer vacation,
Courtney is the Kansas City area pharmacist who stands accused of 20 federal
felony counts alleging that he misbranded, adulterated and tampered with chemotherapy
medications ordered by a Kansas City physician. For the record, he has pleaded
not guilty.
Despite his humble background and relative youth—he is not yet 50—Courtney
has managed to accumulate a not-so-shabby fortune in the neighborhood of $10
million. The key to his success seems to be the simple if diabolical practice
of diluting cancer drugs.
Despite his plea of not guilty, court filings suggest that Courtney has acknowledged
diluting Gemzar, Taxol, Paraplatin and Platinol in over 150 chemotherapy treatments
for 34 local oncology patients. If true, the ramifications are frightening
and incalculable. At least one of the affected patients has already died.
It is the insidiousness of the deed and its ineffable sense of betrayal, more
than the results themselves, that have provoked so huge a public outcry. The
local media have paid more attention to Courtney than to any accused evil
doer since Bob Berdella. The FBI still has 25 agents on the case despite the
national search for terrorists. No fewer than 40 lawsuits have been filed.
And perhaps most poignantly, Richard and Annette Bloch staged a public rally
at their Cancer Park to comfort victims and those who worried that they might
be.
“This has given Kansas City a terrible name,” Richard Bloch told
the crowd. “We want to show the world that Kansas City has a big heart.”
All of this for a shy, geeky, minister’s kid turned pharmacist who just
wanted to live life larger than he might have had he lived it straight. There
is, in fact, a sense of disproportion here. As with Osama bin Laden, one wishes
for a grander enemy, one more worthy of the community’s wrath, not just
a corruptible human soul whose baseness is as old as mankind.
Given the human failings of the case, there is more talk in the air today
about punishment than solutions. Moving beyond Courtney, trial lawyers seek
redress not so much where the problem is keenest but where the pockets are
deepest. To that end, several suits have already been filed against Eli Lilly
and Co., manufacturer of the drug Gemzar. These suits contend that the company
ignored information from one of its salesmen that Courtney was diluting drugs
more than a year before the case broke open.
Despite the fact that Lilly calls the charges “ridiculous and untrue,”
The Kansas City Star has admonished Lilly in particular and corporate America
in general “to make sure their operations are not merely within the law
but are guided by strong ethical values.”
But the law suits and The Star, and even Lilly in its response, impute police
power to the vendor that belongs to the state, if to any agency. They suggest,
in effect, that a vendor has the responsibility not just for making safe products,
but for tracking their use by their clients. And right now, there is no system
to accomplish any such thing among payers or regulators let alone among vendors.
“Bits and pieces are in place today,” says Blair, himself a pharmacist
and an authority on such systems, but “no system.” As Blair and
others observe, however, the absence of a system not only emboldens people
like Courtney, but it also allows medication error to persist throughout the
health-care system. And if a case like Courtney’s is rare in one of America’s
most highly trusted professions,
medication error is not.
“We really don’t know how big the problem is,” says Blair.
The dispensation of drugs today remains, for the most part, unchanged from
the way it was done a century ago. Doctors write prescriptions that often
border on the indecipherable while pharmacists, nurses and other caregivers
struggle to translate them into the appropriate medication. Curiously, this
practice is still looked on as quaint and even charming.
Traditionally, the public has trusted pharmacists in particular to make sense
of the handwriting and distribute good cheer and free advice along with the
medication. In fact, it is the high level of trust that people bestow on the
pharmacist that makes the Courtney case so shocking and offensive.
The case could have a positive effect, however, if it alerts the public to
the larger problem of medication error, which today takes many forms, among
them:
• Incomplete patient information about allergies,
other medication being used, previous diagnoses, and lab results.
• Unavailable drug information such as lack
of up-to-date warnings and expirations.
• Miscommunication of drug orders due to
poor handwriting, confusion between drugs with similar names, the misuse of
zeroes and decimal points, confusion of metric and other dosing units, and
inappropriate abbreviations.
• Lack of appropriate labeling as a drug
is prepared and repackaged into smaller units.
Current wisdom on addressing medication error is surprisingly primitive. Most
institutions seem to rely on ad hoc systems often developed internally through
trial and error. Indeed, it is not uncommon to see guidelines for pharmacists
as broad and as unhelpful as the following: “Analyze aggregate data to
determine trends, significance, frequency, and outcomes of medication errors.”
What is needed, Blair notes, is a standardized, system-wide program of “positive
patient identification.” He finds it “ridiculous,” for instance,
that drugs today still do not have bar codes. These codes could be imprinted
at the time of manufacture so that the lot number and the expiration date
could easily be traced throughout the whole system: from manufacturer to wholesaler
to pharmacist to caregiver to patient. Now there is typically a computer link
from payer to pharmacy, but that link tracks little more than cost and volume.
This does the patient little good and little good also for investigators who
are checking on errant pharmacists such as Courtney. To make their case, they
are forced to wade through reams of paperwork and recreate case records.
Blair believes that the technology now exists to create a viable, largely
paperless system, and Cerner, in fact, is working on elements of it. If not
immune to bugs, this system has the potential to greatly reduce the human
error now endemic in drug distribution and, at the least, “allow a last
check at the bedside.”
To work at its best this system would require “a collaborative effort”
of all the major players including the pharmaceutical companies, the hospitals,
the pharmacists and the payers. If the Courtney case inspires these participants
to act sooner rather than later, the amount of energy invested in Courtney’s
case will not have been in vain.
But ironically, although such a system will cause the Courtneys of the world
to be more circumspect, it will not stop them. As the Dreiser novel suggests,
greed runs just too deep in human nature and assuredly always will.