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

2. MERP – New Hospital Survey  Hospitals, Surgical Clinics and Special Hospitals adopt a formal plan to eliminate or substantially reduce medication-related errors –Health & Safety Code 1339.63  Facility MERPs submitted to CDPH (formerly CDHS) by January 1, 2002 – for review and approval.

3. 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)

4. 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)

5. MERP Requirements  Must include technology (e.g. CPOE)  Implemented January 1, 2005  Compliance with “Plan Elements” –– Added secondary to SB 801 – emergency legislation

6. 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:

7. 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).

8. 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.

9. 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.

10. Beginning January 1, 2005, the Department (CDPH) shall monitor implementation of each facility’s plan upon licensure visit.

11. 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

12. 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

13. Survey Expectation AFL  MERP implemented by 1/1/05 –How has your plan evolved? –Current activities need to address all 11 elements  Use of Technology –Did you implement what you proposed? –If not what have you done and does it demonstrate reduction in errors?

14. 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?

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

16. Survey Expectation AFL  System to proactively identify potential and actual errors –How do you identify potential errors? –Does your system promote error reporting? –Health and Safety Code 1279.6 – Patient Safety Plan shall include A reporting process that supports and encourages a culture of safety and reporting patient safety events.A reporting process that supports and encourages a culture of safety and reporting patient safety events.

17. 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?

18. 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

19. 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

20. 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

21. Survey Process  2002 CDPH approved MERP  Reconcile with current facility MERP – 2005 to current  Paper to process evaluation

22. 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

23. Questions