California Hospital Association Medication Safety Committee An interagency, interdisciplinary committee for safe medication use. Jeannette Hanni, R.Ph., M.P.A., FCSHP Co-Chair, CHA Medication Safety Committee
Patient Safety Legislation in CA Senate Bill 1301 Promote patient safety by ensuring that there is a system in place for early detection of, and response to, systemic problems that cause adverse healthcare events leading to death or serious disability, 2006 California Department of Public Health All facility Letter July, 2007 Mandatory Reporting of adverse events
Patient Safety Legislation in CA, cont Senate Bill 1875 (Jan 2001) and SB 801 (Mar 2002) All general acute care hospitals, surgical clinics, and special hospitals adopt a plan to eliminate or substantially reduce medication related errors California Department of Health All Facilities Letter Dec 2008 Notification of the intent to survey to monitor facility implementation of their CDPH approved MERP (medication error reduction plan) beginning Jan 2009
Genesis of the Med Safety Committee Many hospitals began to receive fines heparin recall Many incidents were medication related Top leadership at CHA and CDPH began conversations about the new legislation and the resulting hospital experiences The CDPH Deputy Director approaches CHA about hosting an interagency, interdisciplinary medication safety committee composed of various agencies and health care organizations in 2009
CHA Medication Safety Committee - Guidelines The Committee consists of 16-35 representatives from the following organizations: California Department of Public Health California Society of Health System Pharmacists California Board of Pharmacy Centers for Medi-Care and Medi-Caid Services Association of California Nurse Leaders California Medical Association California Hospital Patient Safety Organization Risk Management Association
CHA Medication Safety Committee - Guidelines Representatives from the following CHA committees/centers: Center for Behavioral Health Rural Health Center Quality Committee Joint Committee on Accreditation and Licensing Center for Hospital Medical Executives EMS/Trauma Committee Hospital Based Clinics Committee Center for Rehabilitation Services Hospital Services for Continuing Care Committee Governance Quality Directors Health Informatics and Technology Committee
CHA Medication Safety Committee - Guidelines Representatives were also chosen from large hospital systems, public institutions, private facilities, free-standing facilities, small and rural facilities, university/teaching facilities and specialty facilities. Membership was appointed by CHA staff Two co-chairs were chosen to lead the committee
CHA Medication Safety Committee Mission The mission of the Medication Safety Committee is to provide leadership within the health care community to promote the highest standards related to the safe and effective use of medications
CHA Medication Safety Committee Purpose The purpose of the Medication Safety Committee is to provide a forum for diverse multi-disciplinary health care organizations, that include health care delivery organizations, patient safety organizations, discipline specific professional association/organizations and regulatory agencies, to promote safe medication practices in the state of California. The Committee will focus on acting as a source of medication safety expertise, providing a venue for the coordination of medication safety activities and making recommendations related to medication safety legislation and regulations.
CHA Medication Safety Committee Member Responsibilities Provide hospital-industry leadership to the Committee Identify issues and develop possible solutions and best practices to improve the safety of medication storage and distribution administration. Work cooperatively with key stakeholders to develop creative solutions. Provide communication to member hospitals regarding medication safety issues. Maintain/increase awareness of the legislative and regulatory environment with regard to medication safety issues.
CHA Medication Safety Committee Subcommittees Three subcommittees The MERP subcommittee The Hospital Emergency Department subcommittee The High-Risk High-Alert Medications subcommittee
CHA Medication Safety Committee - Subcommittees The MERP (medication error reduction plan) Subcommittee was created to Keep abreast of the current CDPH findings To look for opportunities to gain insight and to provide feedback to the CDPH regarding survey findings and process To look for opportunities to provide the health care community with tools to prevent future findings and to improve patient safety. To standardize the survey process
CHA Medication Safety Committee - Subcommittees The Hospital Emergency Room Subcommittee was created to: Review the current medication practices in the Emergency Room Special emphasis was placed on determining the use of ADMs in the Emergency Room Special emphasis was also placed on determining the current progress towards the placement of a pharmacist presence in the emergency room setting
CHA Medication Safety Committee - Subcommittees The High-Risk, High-Alert medications subcommittee was created to: Bring together medication safety officers, pharmacy association staff, pharmacy directors/staff, and regulators. Identify drugs that pose a high risk to patients. Create guidelines for the safe and effective storage, preparation, and administration of high risk medications. To date, the subcommittee has created a best practice guideline on fentanyl and has started its second guideline on anticoagulants.
Best Practice Guideline on Fentanyl Transdermal Patches
Next Steps The subcommittees have been re-evaluated for efficacy and relevance to current practice. The Committee is dissolving the MERP subcommittee The Committee is creating a new subcommittee called Care Transitions to address this important step when patients transition to different levels and sites of care. The Committee will also be moving the ED practice subcommittee into the Care Transitions subcommittee
Conclusion This inter-agency, multidisciplinary committee for safe medication use was first convened in December, 2009. The Committee is composed of state regulators and licensing boards, professional societies and associations, quality organizations for healthcare, and practitioners from many different practice settings. Members serve voluntarily at the appointment of the California Hospital Association. The members provide leadership within the health care community to promote the highest standards related to the safe and effective use of medications.
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