California Department of Public Health Loriann De Martini, Pharm.D. Chief Pharmaceutical Consultant Center for Healthcare Quality Medication Error Reduction.

California Department of Public Health

Loriann De Martini, Pharm.D.Chief Pharmaceutical Consultant

Center for Healthcare Quality

Medication Error Reduction Plan (MERP)

MERP – New Hospital Survey MERP – New Hospital Survey

Hospitals, Surgical Clinics and Special Hospitals, Surgical Clinics and Special Hospitals adopt a formal plan to eliminate or Hospitals adopt a formal plan to eliminate or substantially reduce substantially reduce medication-related medication-related errorserrors– Health & Safety Code 1339.63Health & Safety Code 1339.63

Facility MERPs submitted to CDPH Facility MERPs submitted to CDPH (formerly CDHS) by January 1, 2002 – for (formerly CDHS) by January 1, 2002 – for review and approval.review and approval.

Medication-related Error

“Any preventable medication-related event that adversely affects a patient in a facility that is related to professional practice, or health care products, procedures, and systems, including, but are not limited to, …”

Health and Safety Code (H&S) 1339.63 (d)

Medication-related Error

Prescribing

Prescription order communication

Product labeling

Packaging and nomenclature

Compounding

Dispensing

Distribution

Administration

Education

Monitoring

Use

Health and Safety (H&S) Code 1339.63(d)

MERPMERPRequirementsRequirements

Must include technology (e.g. CPOE) Must include technology (e.g. CPOE) Implemented January 1, 2005 Implemented January 1, 2005 Compliance with “Plan Elements” –– Added Compliance with “Plan Elements” –– Added

secondary to SB 801 – emergency legislation secondary to SB 801 – emergency legislation

Plan Elements

Lack of plan review criteria resulted in need for emergency legislation

Senator Speier adopted the work of an advisory committee of stakeholders convened by CDPH Pharmaceutical Consultant Unit. - Issuance of an All Facilities Letter (AFL)– 10/31/2001

SB 801 passed 3/21/2002 – H&S Code 1339.63 (e)(1-7). In addition to incorporation of technology each plan shall:

Plan Elements

1. Evaluate, assess, and include a method to address each of the procedures and systems listed under subdivision (d) to identify weakness or deficiencies that could contribute to errors in the administration of medications.

2. Annual review to assess the effectiveness of the implementation of each of the procedures and systems listed under subdivision (d).

Plan Elements

3. Modified as warranted when weaknesses or deficiencies are noted to achieve the reduction of medication errors.

4. Describe the technology to be implemented and how it is expected to reduce medication errors.

5. Include a system/process to proactively identify actual or potential errors. Shall include concurrent and retrospective review of clinical care.

Plan Elements

6. Multidisciplinary process to regularly analyze all identified actual or potential errors and describe how the analysis will be utilized to change current procedures and systems to reduce errors.

7. Include a process to incorporate external medication-related error alerts to modify current processes and systems as appropriate.

Beginning January 1, 2005, the Department (CDPH) shall monitor

implementation of each facility’s plan upon licensure visit.

MERP Survey Process Development

Conducted six stakeholder meetings in collaboration with the hospital associations – January-June 2008– Los Angeles, Inland Valley, Orange, San

Francisco, Sacramento and San Diego – Objective: Understand legal elements of MERP

that dictate proposed survey process and provide opportunity for input in the development of MERP survey process.

– Representatives from approximately 72 hospitals participated

MERP Survey Process Development

Outcomes of Stakeholders Participation– Issuance of a Survey Notification AFL –

March 28, 2008– Conducted two “Table Top” survey

simulation exercises with four hospitals – Los Angeles and Sacramento - September

• Representatives from 30 hospitals participated

– Issuance of a Survey Expectation AFL – December 8, 2008

Survey Expectation AFLSurvey Expectation AFL

MERP implemented by 1/1/05MERP implemented by 1/1/05– How has your plan evolved?How has your plan evolved?– Current activities need to address all 11 Current activities need to address all 11

elementselements Use of TechnologyUse of Technology

– Did you implement what you proposed?Did you implement what you proposed?– If not what have you done and does it If not what have you done and does it

demonstrate reduction in errors?demonstrate reduction in errors?

Survey Expectation AFL

Evaluate, assess and address each of the 11 elements to identify weakness.– How did you use the assessment to address

system deficits?– Where the implementations strategies

effective? And how do you know? MERP re-evaluated annually.

– How have you address the 11 elements on an annual basis?

Survey Expectation AFLSurvey Expectation AFL

Upon review the MERP is modified when Upon review the MERP is modified when necessary to achieve reduction of errorsnecessary to achieve reduction of errors– What weakness have you noted upon review?What weakness have you noted upon review?– What actions did you take to address?What actions did you take to address?– How was the plan modified?How was the plan modified?– Was the revised plan effective?Was the revised plan effective?

Survey Expectation AFLSurvey Expectation AFL

System to proactively identify potential and System to proactively identify potential and actual errorsactual errors– How do you identify potential errors?How do you identify potential errors?– Does your system promote error reporting?Does your system promote error reporting?– Health and Safety Code 1279.6 – Patient Health and Safety Code 1279.6 – Patient

Safety Plan shall includeSafety Plan shall include• A reporting process that supports and A reporting process that supports and

encourages a culture of encourages a culture of safetysafety and reporting and reporting patient patient safetysafety events. events.

Survey Expectation AFL Errors are analyzed to identify opportunities for

improvement– What is your process for analyzing errors?– How has prior analysis been used to change

procedures or systems? Process to incorporate external alerts.

– What type of alerts do you use and how?

Survey Expectation AFL

Method to determine effectiveness.– How do you know a specific action is

working to reduce errors?– Response is based on sound clinically

relevant documentation or literature to support the response

MERP Survey Process Surveys managed by Pharmaceutical

Consultant Unit and coordinated with District Office and LA County.

Surveys are Triennial Facilities will be provided advance notice -90

day survey window Opportunity to provide input on survey dates Forty hospitals have been noticed that they

will be surveyed between 1/12 and 6/30/2009 Forty hospitals slated for survey third quarter

MERP Survey Process Request following information

– Current MERP and revisions back to 2005– QAPI data related to medication errors for last 36

months– P&T committee minutes and/or committees involved

in overseeing MERP – 36 mos– Reports including metrics related to medication error

reduction – 36 mos– Documentation of annual review of MERP since

2005– MERP multidisciplinary team members, positions,

locations and phone numbers

Survey Process

2002 CDPH approved MERP Reconcile with current facility MERP – 2005

to current Paper to process evaluation

MERP Survey Findings 13 hospitals

– 23% - no deficiencies 10 hospitals – 27 deficiencies

– 41% - Title 22 – 59% - Health and Safety Code

Common findings– Annual review to assess effectiveness– Modified when weakness is identified– Evaluate each process– P&T committee – policy and procedures

Questions