More states require med-error reports

May 15, 2005

Does your state require the reporting of medication errors? If the answer is No, get ready for a change. Twenty-three states, including California, Florida, New York, and other major hospital population centers, already mandate med-error reports. Another six states are actively considering legislation, according to on-line publisher NETSCAN, based in Falls Church, Va.

"I expect to see the trend continue, with mandatory reporting coming to other states," said NETSCAN Health Policy Tracking Service policy analyst Andrew McKinley.

North Carolina was the first state to require reporting of medication-related fatalities, said Carmen Catizone, executive director of the National Association of Boards of Pharmacy. The state enacted its first mandatory reporting requirements in 1992. Since then, mandatory reporting has expanded from drug-related fatalities to include any significant medication-related event. Reports are kept confidential. "We were one of the pioneers in reporting," said David Work, executive director of the North Carolina Board of Pharmacy. "The response has been underwhelming."

By 2004, the American Medical Association counted 20 states with some form of mandatory error reporting. The list grew to 23 states when a Wyoming bill was signed into law on March 15. The new law requires health providers, including hospitals, to report "safety events" to the state health department. Safety events are defined as any "unexpected occurrence involving death or serious physical or psychological injury or the risk thereof" from causes that include medication errors. Reports are shielded from public disclosure and use in legal proceedings, but aggregate data are published in an annual report.

"We didn't see any significant problems and supported the bill," said Linda Martin, executive secretary of the Wyoming Society of Health-System Pharmacists.

Similar moves toward mandatory reporting can't come too soon for many pharmacy groups. NABP has been pushing mandatory error reporting for years. So has ASHP, which took a policy stand in favor of mandatory reporting in 2000.

Errors and quality One problem is that most states have different systems. Some states have mandatory reporting and keep all reports confidential. Other states reveal reports. Pharmacy and patient advocacy groups support mandatory reporting, Catizone noted. But while most pharmacy groups favor shielding reports from disclosure to avoid penalizing individuals, consumers generally favor disclosure in the belief that fewer errors equate to higher quality of care.

The Kaiser Family Foundation, the Agency for Healthcare Research and Quality, and the Harvard School of Public Health surveyed public attitudes in 2004. They found that 70% of the public believe that reports of errors in hospitals tell them a lot about the institution's quality. And it's the same on the health plan side.

"Error reports don't work that way," said Michael Cohen, president of the Institute for Safe Medication Practices. ISMP administers Pennsylvania's system for reporting med errors, the Pennsylvania Patient Safety Reporting System, or PA-PSRS. "Error reports are indicative of the number of errors being reported, not the kind of errors being made," he said. "You can expect fewer errors or more errors depending on the kind of patients you treat, the drugs you're using, any number of variables. Then there are variables in what gets reported and what doesn't. To use these data to compare hospitals is terribly misleading. That's why Pennsylvania and ISMP keep all error reports confidential."