BILL ANALYSIS
SENATE HEALTH
COMMITTEE ANALYSIS
Senator Deborah V. Ortiz, Chair
BILL NO: SCR 49
S
AUTHOR: Speier
C
AMENDED: June 15, 2005
R
HEARING DATE: June 22, 2005
FISCAL: Non-Fiscal
4
9
CONSULTANT:
Margolis / ag
SUBJECT
Medication errors: creation of legislative panel
SUMMARY
This resolution makes findings related to the dangers and
causes of medication errors, and resolves that a special
panel be formed by the California Legislature to study the
causes of medication errors and submit a final report to
the Senate Committee on Health by June 1, 2006.
ABSTRACT
Existing law:
1.Requires every pharmacy to establish a quality assurance
program that documents mediation errors attributable to
the pharmacy or its personnel.
This bill:
Includes the following findings:
1.Numerous studies establish that medication errors cause
injury and death.
2.The Institute of Medicine estimates annual drug-related
morbidity and mortality costs to be approximately $77
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million nationally.
3.Research demonstrates that medication errors result from
the failures of a complex healthcare system and are not
the fault of individual healthcare providers.
4.Over 17,000 trade and generic products exist, for which
many of the names are similar, and many are packaged
similarly.
5.Many factors contribute to a poor understanding by
patients about their prescriptions.
6.Improved communication between patients and their health
professionals is the most effective means of reducing
medication errors.
Resolves that:
1.The Legislature convene a special panel to study causes
of medication errors no later than October 1, 2005.
2.The panel recommend improvements, additions, or changes
to improve the health care system by reducing medication
errors.
3.The panel shall consist of appointees of the Health
Committees of the Senate and Assembly.
4.The Speaker of the Assembly shall appoint a member of the
faculty of a school of pharmacy; representatives of: the
California Pharmacists Association, the California
Association of Health Plans, the Pharmaceutical Research
and Manufacturers of America, the California Medical
Association, the Assembly Republican Caucus; and a
consumer representative.
5.The Senate Committee on Rules shall designate the panel's
chair and appoint representatives from: the California
Retailers Association Chain Drug Committee, the Generic
Pharmaceutical Association, the California Society of
Hospital Pharmacists, a public health organization, the
California Nurses Association, the American Association
of Retired People, and the Senate Republican Caucus.
6.The panel shall submit to the Senate Committee on Health
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a preliminary report by March 1, 2006, and a final report
by June 1, 2006.
7.The members of the panel shall not receive compensation
but shall be reimbursed for travel expenses, and the
panel shall be funded by private sources.
FISCAL IMPACT
This is a non-fiscal bill and requires that the panel be
funded by private sources.
BACKGROUND AND DISCUSSION
Medical errors
A seminal 1999 report by the Institute of Medicine (IOM),
To Err Is Human: Building a Safer Health System,
effectively launched a national discussion about the
seriousness and gravity of medical errors in this country.
The report states that between 44,000 and 98,000 people die
in hospitals each year as a result of medical errors that
could have been prevented. According to the report,
"Preventable medical errors in hospitals exceed
attributable deaths to such feared threats as motor-vehicle
wrecks, breast cancer, and AIDS." The report describes the
high and varied types of costs that result from medical
errors, totaling between $17 and $29 billion per year in
hospitals nationwide. Other costs cited include: loss of
trust in health care; physical and psychological
discomforts for patients; loss of morale and frustration by
providers; lost worker productivity; and increased school
absences by children.
The IOM study explores the causes of medical errors and
concludes that "The majority of medical errors do not
result from individual recklessness?errors are caused by
faulty systems, processes, and conditions that lead people
to make mistakes or fail to prevent them." Within this
report, the IOM lays out a comprehensive strategy to reduce
preventable medical errors, concluding that the ways to
prevent these errors already are known. The strategy
includes the following four major goals:
1.Establish a national focus to create leadership,
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research, tools, and protocols to enhance the knowledge
base about safety. Specifically, the IOM recommended
that Congress create a "Center for Patient Safety, within
the Agency for Healthcare Research and Quality (AHRQ), to
set national safety goals, develop a research agenda, and
develop, disseminate, and evaluate tools for identifying
and analyzing errors, among other tasks.
2.Develop a nationwide public mandatory reporting system
and encourage health care organizations and practitioners
to develop and participate in voluntary reporting
systems. State governments would be required to collect
standardized information; hospitals would be required to
begin reporting first, and eventually all health care
organizations would report.
3.Raise performance standards and expectations for
improvements in safety through the actions of oversight
organizations, professional groups, and group purchasers
of health care. The IOM argues that setting and
enforcing explicit performance standards for patient
safety through regulatory and related mechanisms, such as
licensing, certification, and accreditation can define
minimum performance levels for health professionals. The
report states that professional societies should become
leaders in encouraging and demanding improvements in
patient safety, by setting their own performance
standards, communicating with members about safety, and
collaborating across disciplines. Public and private
purchasers are urged to make safety a prime concern in
their contracting decisions.
4.Implement safety systems in health care organizations to
ensure safe practices at the delivery level. The report
states that, "Safety should be an explicit organizational
goal that is demonstrated by strong leadership on the
part of clinicians, executives, and governing bodies."
This includes: designing jobs and working conditions for
safety; standardizing and simplifying equipment,
supplies, and processes; and enabling care providers to
avoid reliance on memory.
According to the IOM, many actions have occurred to
implement these strategies since the issuance of the report
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in 1999, including:
Congress appropriated $50 million to the AHQR to: develop
and test new technologies; conduct large-scale
demonstration projects; and support new and established
multidisciplinary teams of researchers in health-care
facilities and organizations.
The National Academy for State Health Policy convened
leaders from both the executive and legislative branches
of the states to discuss approaches to improving patient
safety.
The Leapfrog Group, an association of private and public
sector group purchasers, unveiled a market-based strategy
to improve safety and quality.
The Council on Graduate Medical Education and the
National Advisory Council on Nurse Education and Practice
held a joint meeting on educational models to ensure
patient safety.
In May of 2005, two of the original authors (Lucien Leape,
M.D., and Donald Berwick, M.D.) of To Err is Human
published a follow-up study of progress made in the five
years following the IOM report. The authors conclude that,
"The groundwork for improving safety has been laid in these
past five years but progress is frustratingly slow." They
also state that small improvements can be seen at the
margins, but the overall national situation remains largely
the same. This follow-up report cites the following
barriers to change: creating a culture of safety requires
changes that physicians may perceive as threats to their
autonomy and authority; fear of malpractice liability leads
to an unwillingness to discuss or admit errors; the
complexity of the health care industry; a lack of
leadership; the lack of measures to gauge progress; and the
current reimbursement system that rewards less-safe care.
Leape and Berwick argue that the single most important next
step is to set and adhere to "strict, ambitious,
quantitative, and well-tracked national goals."
Medication errors
The National Coordinating Council for Medication Error
Reporting and Prevention is dedicated to preventing medical
errors specific to medications. The organization includes
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the following members: AARP, American Health Care
Association, American Hospital Association, American
Medical Association, American Nurses Association, American
Pharmacists Association, American Society of Health-System
Pharmacists, Food and Drug Administration, Generic
Pharmaceutical Association, and others. This organization
has issued recommendations on reducing medication errors in
non-health care settings, reducing errors associated with
verbal medication orders, reducing errors related to
administration of drugs, error-prone aspects of dispensing
medications, labeling and packaging of drugs, and more.
The California Pharmacists Association, the sponsor of the
bill, writes in support that "SCR 49 will create a
credentialed panel to study the systemic causes of these
errors, and make substantive recommendations to reduce them
for the protection of the public and for healthcare cost
reductions." The California Nurses Association states in
support that this panel "will bring together a diverse
group of individuals to look at the cause of millions of
needless consumer deaths or disabilities due to preventable
medication errors." Kaiser Permanente writes in support of
the bill that, "This panel would be able to take an
informed, independent look at new technologies and
different processes that could be used to reduce medication
errors."
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Prior legislation
SR 44 (Burton, 2004) -- requires the Senate to establish
the California Commission on the Fair Administration of
Justice to study and review the administration of
criminal justice in California, to determine the extent
to which that process has failed in the past, resulting
in wrongful executions or the wrongful convictions of
innocent persons. The Commission must be funded
privately and make recommendations to the Legislature and
Governor by December 31, 2007.
SCA 39 (Soto, Chapter 142, Statutes of 2001) -- required
the Senate Committee on Public Employment and Retirement
to convene a panel to study the funding of pharmacy
benefits, co-payments, and other benefit structures of
the Public Employees' Medical and Hospital Care Act
program, and report back to the Committee by June 1,
2002. The sponsor of SCR 49 states that the SCA 39
process was considered successful by those involved and
that valuable recommendations were produced by the panel.
Author's amendment
The author would like to offer an amendment in Committee to
add to the panel a representative of the Consumer
Healthcare Products Association, to be appointed by the
Senate Rules Committee.
POSITIONS
Support: California Pharmacists Association (sponsor)
California Nurses Association
Kaiser Permanente
Oppose: None received.
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