Legislative Policy Presentation BySenator Richard T. Moore

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Identifying and Preventing Medication Errors
A Study by the Institute of Medicine Committeeon
Identifying and Preventing Medication Errors
Legislative Policy Presentation By Senator
Richard T. Moore Senate Chair, Committee on
Health Care Financing Massachusetts General
Court April 14, 2005 Washington, D.C.
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OVERVIEW
Massachusetts Birthplace of the Patient
Safety Movement
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MASSACHUSETTS COALITION FOR THE PREVENTION OF
MEDICAL ERRORS
Coalition Mission Statement The Massachusetts
Coalition for the Prevention of Medical Errors
was established to improve patient safety and
minimize medical errors.

• The goals of the coalition are to
• Establish a mechanism to identify and implement
  best practices to minimize medical errors
• Increase awareness of error prevention
  strategies through public and professional
  education
• Identify areas of mutual interest and minimize
  duplication of regulatory and Joint Commission
  for the Accreditation of Healthcare Organizations
  (JCAHO) requirements so that efforts are focused
  on initiatives that can best improve patient
  care.

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MASSACHUSETTS COALITION FOR THE PREVENTION OF
MEDICAL ERRORS
About the Coalition The Massachusetts Coalition
for the Prevention of Medical Errors was
established in 1998 to develop a campaign in the
Commonwealth to improve patient safety and reduce
medical errors. The goals of the Coalition are
to disseminate knowledge and information about
the causes of sentinel events and develop
strategies for prevention. The Coalition plans to
drive improvement by making this information
available to health professionals and health care
institutions for use in their own quality
improvement programs through a statewide
campaign. This initiative seeks to strengthen
the public's trust and confidence in the health
care delivery system as well, by increasing
awareness of error prevention strategies through
public and professional education.
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MASSACHUSETTS COALITION FOR THE PREVENTION OF
MEDICAL ERRORS
Member Organizations
AARP Massachusetts Alliance for Health Care
Improvement AORN (Association of periOperative
Registered Nurses) Boston Medical Center Brigham
Women's Hospital Cambridge Health Alliance Cape
Cod Health System Center for Patient Safety in
the Neo-Natal Intensive Care Unit Centers for
Medicare and Medicaid Services Children's
Hospital Dana-Farber Cancer Institute Division of
Professional Licensure Group Insurance
Commission Harvard School of Public Health Health
Care for All Institute for Healthcare
Improvement Joint Commission on Accreditation of
Healthcare Organizations Joint Committee on
Healthcare Lahey Clinic Mass. Association of
Behavioral Health Systems Mass. Association of
Health Care Quality Mass. Association of Health
Plans Mass. Board of Registration in
Nursing Mass. Board of Registration in
Pharmacy Mass. Board of Registration in
Medicine Mass. Department of Mental Health Mass.
Department of Public Health Mass. Division of
Medical Assistance
Mass. Extended Care Federation Mass. General
Hospital Mass. Health Council Mass. Health
Quality Partners, Inc. Mass. Healthcare Purchaser
Group Mass. Hospital Association Mass.
Independent Pharmacists Mass. Medical
Society Mass. Nurses Association Mass.
Organization of Nurse Executives MassPRO Mass.
Pharmacists Association Medically Induced Trauma
Support Services (MITSS) Mount Auburn
Hospital Newton-Wellesley Hospital Northeast
Health System Partners HealthCare
System Professional Liability Foundation ProMutual
Group Risk Management Foundation Salem State
College Southcoast Hospitals Group Sturdy
Memorial Hospital Tufts Health Plan Tufts-NEMC UMa
ss Memorial Medical Center VHA Northeast
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CONSUMER GUIDE TO MEDICATION SAFETY
The Massachusetts Coalition for the Prevention of
Medical Errors has developed a consumer guide
that encourages patients to become "part of the
health care team" along with their physicians,
nurses, and pharmacists, to prevent medication
mistakes. The guide was developed in
conjunction with the Washington, D.C.-based
Institute for Family-Centered Care and is based
on input solicited from patients, families, and
health care professionals. The brochure is also
available in Spanish. For more information,
contact Massachusetts Coalition for the
Prevention of Medical Errors Phone
781-272-8000 ext.221 Email macoalition_at_mhalink
.org
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STATE PATIENT SAFETY CENTERS
FLORIDA MARYLAND MASSACHUSETTS NEW
YORK OREGON PENNSYLVANIA
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MISSION OF STATE PATIENT SAFETY CENTERS
All six centers

• improving, ensuring, or promoting patient safety.

Other common features of many of the centers
include

• fostering a culture of safety,
• educating about patient safety, and
• potentially serving as a data repository

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MASSACHUSETTS
Betsy Lehman Center
Massachusetts mission statement is unique in
its emphasis on coordinating functions. The
mission includes coordinating patient safety
programs across state agencies, between the
state and federal level, and between private and
public sectors.
National Academy for State Health Policy
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NURSE TO PATIENT STAFFING RATIO LEGISLATION
CALIFORNIA Enacted MASSACHUSETTS
Proposed NEW JERSEY Proposed MARYLAND
Proposed VERMONT Proposed INDIANA Proposed
PROPOSED BY NURSES UNIONS
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STATE LAWS ENACTED AFFECTING PHARMACEUTICAL
MARKETING 5 STATES
CALIFORNIA (2004) MAINE (2003) VERMONT
(2002) WEST VIRGINIA (2001) MINNESOTA (1993)
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2005-2006 SESSION LAWS AFFECTING PHARMACEUTICAL
MARKETING 17 STATES
New Hampshire New Mexico New York Oklahoma Tenness
ee Vermont Washington Wyoming
Connecticut Florida Hawaii Illinois Maine Massachu
setts Montana Mississippi Nevada
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PHARMACEUTICAL MARKETING
- With expanded utilization and increased costs
of drugs, state legislators in every state have
expressed concerns of drug ads and marketing
practices. - Estimated annual cost of 2.5
billion, pharmaceutical advertising to
consumers - The managed care industry reports
that from 1999 to 2000, prescriptions written
for the top 50 most heavily advertised drugs rose
24.6 percent, compared to 4.3 percent for all
other drugs combined. - Drug manufacturing is
a 122 billion industry, so a small increase in
market share can reflect a multimillion-dollar
boost for any particular company.
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DISCLOSURE OF CLINICAL TRIAL RESULTS
MINNESOTA House Bill No. 1668 TENNESSEE
Senate Bill No. 115 TEXAS House Bill No. 1029
VERMONT House Bill No. 1029
PROPOSED BY CONSUMERS UNION
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MASSACHUSETTS

• Senate Bill No. 275 (Moore et al.) that would
  create an Advanced Technologies Health Care Trust
  Fund to assist health care providers with zero
  interest loans to help off-set the initial cost
  of utilizing CPOE (computerized physician order
  entry ) systems or EPR (electronic patient
  records)
• Senate Bill No. 408 (Moore et al.) to establish a
  voluntary collaborative drug therapy management
  program to improve pharmaceutical care for
  patients.
• Senate Bill No. 1276 (Moore et al.) for safe
  administration of medications and legible
  prescriptions would direct the Betsy Lehman
  Center to study methods for reducing medication
  and prescription errors.

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MASSACHUSETTS

• Senate Bill No. 1283 (Moore et al.) for a
  one-time bonus to health care providers for
  implementation of medical error reduction
  technology.
• Senate Bill No. 1263 (Moore et al.) providing for
  a study to determine how to implement limitations
  of work hours of medical residents so that sleep
  deprivation is not a danger to the health of
  either patients or physicians.
• Senate Bill No. 1305 (Moore et al.) to improve
  reporting of adverse events in all health care
  facilities to the Betsy Lehman Center.
• Senate Bill No. 1315 (Pacheco et al.) restricts
  administration of medication to only licensed
  health care professionals.

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MASSACHUSETTS

• Senate Bill No. 558 (Baddour et al.) and Senate
  Bill 561 (Barrios et al.) both require insurers
  to cover the expense of speech-based medication
  identification systems to reduce errors.
• Senate Bill No. 374 (Baddour et al.) established
  a certification program for medication
  technicians in long term care facilities.
• Senate Bill No. 1260 (Moore et al.) requires
  hospitals to file staffing plans with Department
  of Public Health and measures nursing care
  sensitive quality outcomes and publicly reports
  the results.
• House Bill No. 1282 (Canavan et al) requires a
  statewide mandatory nurse to patient staffing
  ratio with severe penalties for failure to meet
  ration mandates.

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MEDICATION ERROR LEGISLATION
Michigan House Bill No. 4017 (Kahn) establishes
a system for reporting and preventing
prescription errors. Nebraska Senate Bill No.
446 (Jensen) amends the patient safety
improvement act to harmonize the provision of
the original act.
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PHARMACY QUALITY IMPROVEMENT BILLS
New Jersey Assembly Bill No. 291 (Vandervalk)
requires pharmacists to report prescription
drug-related deaths and substantial bodily
injuries to the Board of Registration of
Pharmacy. Assembly Bill No. 398 (Van Drew) the
Pharmacy Quality Improvement and Error
Prevention Act is designed to strengthen
protections against the occurrence of
medication- related errors by requiring
pharmacies to adopt systematic measures to
address critical health care issues through a
continuous quality improvement program.
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OTHER STATES CONSIDERING PATIENT SAFETY /
MEDICATION ERROR PREVENTION LEGISLATION IN
2005-2006 SESSION
Arizona Georgia Hawaii Illinois Indiana Kentucky M
aryland New Jersey
New Mexico New York Pennsylvania Vermont Virginia
Washington Wyoming
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Primary Challenges for State Legislative
Initiatives
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EXAMPLE MASSACHUSETTS BETSY LEHMAN CENTER
- Inter-branch rivalry - Board of Registration
in Medicine who saw the Center as a challenge to
their authority to discipline doctors -
Medical Society who feared that the Center could
be a third error reporting system. - Trial bar
was especially strong in opposition because the
bill provided for confidentiality of information
submitted to the Center.
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EXAMPLE MASSACHUSETTS BETSY LEHMAN CENTER
Primary Challenges to Legislation - Opposition
from the Health Care Community - Opposition
from the Legal Community - Fragmented State
Approach to Patient Safety - Lack of Funding
- Staffing Shortage and Demands
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Chief Concerns for State Legislators
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Suggestions for Increased Transparency
Coordination
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Provider Education Patient Education State
Policy Make Education
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PROVIDER EDUCATION
- Medical Schools Need to Improve Education of
Physicians in Pharmacology in recognition of the
increase role of drugs in treatment and the
importance of medication safety. - Medical
Schools Need to Improve Education of Pain
Management for the Terminal Ill and Improve
Understanding of Medication for Mental Illness
in Young People. - Medical Schools Need to
Educate Physicians as key members of the health
care team, not simply solo practitioners. - Pharm
aceutical companies should fund generic (not
self-serving) provider and patient education
about reading and following directions for
prescription and OTC drugs and should support
technology for safer drug use.
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PATIENT EDUCATION
- Patients need to be educated about drug use
that there isnt a magic pill for every ill and
that even beneficial drugs can be harmful if
misused. - Patients need to be educated to read
labels and ask physicians more questions about
proper drug use and side effects. - Patients
need to be taught how to be a member of the
medication error reduction team.
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STATE POLICY MAKER EDUCATION
- IOM needs to help create a constituency for
change in medication error as it did with To
Err is Human. - FDA needs more authority and
staff to deal with misleading or false drug
advertising and the public needs education
through an on-line drug ad watch to separate
hype from hope. - IOM needs to explain that
identifying and preventing medication error is
as important as solving the problem of uninsured
for health access.