HOSPITAL PRACTICE

California hospitals brace for med error law's 2002 deadline

California hospitals have less than two months to come up with formal plans to reduce medication errors. The Jan. 1, 2002, deadline is part of legislation sponsored by State Sen. Jackie Speir that became law in 2000. All hospitals in California must submit a medication error reduction plan to state officials by the first day of the new year and put the plan into effect by Jan. 1, 2005.

Hospitals that don't turn error reduction plans into practice on time could lose vital state operating licenses, Speir told the California Society of Health-System Pharmacists annual meeting in October. "There are an estimated 700 preventable deaths from medication errors in California hospitals every year," she said. "We would not tolerate that toll if it were due to preventable airline accidents. But preventable deaths that occur in hospitals are, for all intents and purposes, invisible. That changes on Jan. 1."

California is one of five states—the others are Florida, Massachusetts, New York, and Washington—with new legislation aimed at reducing the toll of medical and medication errors, Speir said. According to a 1999 Institute of Medicine report, medical errors kill between 48,000 and 100,000 Americans annually.

Even at the low end of the mortality range, medical errors are the eighth-leading cause of death in the United States, Speir noted. Two-thirds of medical errors in hospitals are the result of medication errors, she added. Over 75% of medication errors result from problems with the original drug order or drug administration.

"Preventing medication errors is a logical place to start reducing medical errors overall," Speir told a supportive audience. "The key to reducing errors is to improve the system."

Hospital-based studies have shown that including pharmacists on rounds can cut prescription errors by two-thirds, Speir said. Computerized physician order entry (CPOE) systems have slashed Rx errors by 80% in some institutions.

Moving from a central pharmacy to decentralized operations can cut errors 94%, noted Amy Gutierrez, director of pharmacy services at Martin Luther King/Drew Medical Center, a county hospital in Los Angeles. Affiliation with a pharmacy teaching program also slashes medication errors. "Having pharmacy students around keeps us all sharper," she said. "We have to keep up with the latest just to keep up with our students."

Speir's bill requires hospitals to conduct a baseline assessment of medication errors and an annual review. Based on the initial assessment, hospitals must redesign medication systems and implement new technology.

Following the lead of the Joint Commission on Accreditation of Healthcare Organizations, California is not mandating specific changes or technologies. Implementing regulations suggest steps such as banning the use of abbreviations or symbols on orders and implementing CPOE, but hospitals are free to chart their own course. "If your current medication system has not been recently redesigned, a gentle tweak or promising to try harder isn't going to meet the guidelines," Speir cautioned. "Medication errors are a serious problem that demands serious solutions."

JCAHO agrees. New standards on patient safety that went into effect in July of this year require hospitals to reduce errors. "Many times, we view health care from the perspective that we do not make errors," said Ken Hermann, a consultant for Joint Commission Resources and former JCAHO v.p. in charge of surveyors. "Other industries acknowledge error and failure rates and work actively to reduce them. We can learn a lot from high-risk industries such as aviation."

Hermann pointed out that most errors are the result of work systems and processes that allow or even encourage risky behavior. "We seldom look at the system to see where errors can and do happen," he said. "We need to move from looking at what went wrong to looking at how to prevent it from going wrong. We have to adopt an engineering point of view on medication processes."

Illegible handwriting is a major contributor to medication errors, Hermann said, but less than 5% of U.S. hospitals have CPOE systems that eliminate handwriting problems. "We are starting to see medical staff required to print, use word processors, and avoid abbreviations and symbols," he said.

Hermann is also seeing more interest in CPOE. But an electronic order entry system is only as good as its own rules. A badly designed electronic process can create as many errors as a badly designed human process. One major commercial CPOE system is shipped with its highly sophisticated allergy screen set to "no known allergies" as the default, he said. "Does that default setting ring any warning bells?" he asked. "It's all too easy to automate to do things faster but not more accurately."

Fred Gebhart

Fred Gebhart. California hospitals brace for med error law's 2002 deadline.

Drug Topics

2001;22:27.