National panel to issue report on how to reduce med errors

May 15, 2005

How do we improve medication-error rates? Indeed, how do we even set up systems to know whether med-error rates are improving? Should reporting of errors be voluntary or mandatory? And should agencies that receive such reports give the public information on them?

How do we improve medication-error rates? Indeed, how do we even set up systems to know whether med-error rates are improving? Should reporting of errors be voluntary or mandatory? And should agencies that receive such reports give the public information on them?

Given the natural reluctance of people to report drug errors and the consequent underreporting, should we encourage professionals and institutions to increase their reported rates before we begin to reduce those reported rates?

A 17-member committee sponsored by the Institute of Medicine (IOM) is grappling with these issues in an attempt to tell the nation next year how to build a safer medication system.

CMS said the committee's work might be used to develop measures of safety and to inform the work of prescription drug plans to promote safety, among other things. The panel, which includes a range of health professionals, is taking testimony on topics including event-reporting systems, staffing levels, institutional design, organizational approaches, cognitive and human factors, malpractice and legal issues, pharmacy databases, e-prescribing, bar-coding, smart pumps, and education and technology for patients.

Some of the group's first extensive public discussions, held at its second meeting in the Washington, D.C., area in April, indicated that little about planning for improving the system would be easy. For example, Richard Moore (D), a state senator in Massachusetts, warned the panel that even getting attention to the issues is problematic on a state political level.

State legislators, Moore said, "get concerned about medication safety largely when there is a well-publicized event and they get asked by constituents what they are doing about the problem. It doesn't allow for the kind of thoughtful response that's appropriate for public policy. They would prefer to hang someone than find out the cause, because there is more publicity to that." He believes one of the best ways to get the attention of states would be through a report card comparing them on patient safety ratings.

The fragmented status of oversight is a big barrier to safety, noted Loriann De Martini, Pharm.D., chief of the Pharmaceutical Consultant Unit for the California Department of Health Services, Licensing and Certification Program. She asserted that federal enforcement processes vary for different provider categories and that encourages uneven performance. A med error in a long-term care facility could potentially result in civil monetary penalties (CMPs) and raise other certification issues for the facility, she said. "But if I am in a hospital and I encounter similar issues-and I frequently do-no CMPs are imposed."

De Martini also complained, "There is no universally defined performance standard." She said that the expected performance standard for medication safety is only briefly addressed under new federal conditions of participation (CoPs) for hospitals, but there is no such condition for long-term care, surgical centers, or home-health agencies. She also said the surveyors in her office must repeatedly return to healthcare facilities for the same types of issues. Generally, she said, there's little training of surveyors on patient safety or medications.

The IOM panel also expressed concern over the nationwide situation in which unlicensed personnel distribute medications in schools, prisons, and other institutions. With the expanding number of assisted-living facilities, "it's quite extraordinary what is happening with medication distribution," said Linda Cronenwett, Ph.D., dean of the University of North Carolina School of Nursing and a co-chair of the committee. De Martini said California is seeing increasing polypharmacy problems originating in board-and-care homes or residential care facilities and that the skilled-nursing facilities have to deal with those problems after the patients are transferred to them.