CA Medications Error Panel Report
* MEDICATION ERRORS MAY KILL OR INJURE 150,000 CALIFORNIANS YEARLY
* POSSIBLE COST TO STATE $17.7 BILLION EVERY YEAR
* JACKIE SPEIER SAYS SITUATION IS AN "OUTRAGE"
* SCHWARZENEGGER ADMINISTRATION SAYS HEALTH REFORM WILL HELP
* SEN. CORBETT'S SB 472 TO ADOPT MANY PANEL RECOMMENDATIONS

SACRAMENTO -  A highly anticipated report issued Tuesday (March 6) by former State Sen. Jackie Speier, chair of a bi-partisan legislative panel, says that medication errors in all settings may be killing or injuring over 150,000 Californians every year, costing the State $17.7 billion and that the huge human and financial costs are not the result of serious disease but "well intentioned attempts to treat or prevent illness". 

The 27 page in-depth report focuses on the causes of medication errors in the outpatient (community)  setting and recommends changes in the healthcare system to protect people  from errors regarding  the use of prescription and over-the-counter medications. [see full report, titled "Prescription for Improving Patient Safety: Addressing Medication Errors" and executive summary on the CDCAN website at Medication Errors Panel - Full 27 Page Report - (PDF File) ]

Some or most of the panel's recommendations will likely be put into SB 472 by Sen. Ellen Corbett (Democrat - San Leandro, 10th District) [see below for details]

The Medication Errors Panel, made up of 2 state senators, 2 assemblymembers, and 13 persons representing  consumer advocacy groups, health professionals, (including doctors and nurses)  universities, health plans, the pharmacy industry, and community pharmacies) met at the State Capitol 12 times to hear testimony from 32 persons including widely respected national and state experts in pharmacy, medicine, medical technology, healthcare regulation.

Major Impact to Children and Adults With Disabilities, Mental Health Needs & Seniors
The findings of the report will likely have special impact to vulnerable populations in California who rely on medications, including tens of thousands of children and adults with disabilities (including developmental, autism, etc.), children and adults with mental health needs, people with traumatic brain and other injuries, seniors and others. 

According to the Kaiser Family Foundation, 3.4 billion prescriptions were written in 2003 for Americans at a cost of over $163 billion for that year.  Over 17,000 trade and generic products exist, for which  many of the names are similar, and many are packaged similarly. 

State Sen. Sheila Kuehl (Democrat - Santa Monica, 23rd District), author of a major health care reform bill, SB 840, which calls for a "single payer system", commented on the panel's report saying that "Simple errors resulting from medications that look alike or whose names sound alike can prove very dangerous for patients. It's easy to understand how 150,000 Californians could be injured every year due to medication errors. For instance, think of the potential hazardous outcome of prescribing the allergy medicine Zyrtec to a young child and having that child mistakenly receive Zyprexa, a highly potent antipsychotic. It is a simple mistake yet it can have devastating consequences."

Speier Says Situation Is An "Outrage"
Speier, a Democrat from Hillsborough (near San Francisco) and forced out of the State Senate due to term limits last year, said that it was an "outrage" that actions such as those recommended by the Medication Errors Panel have not yet already been put in place in the State.

"Not enough has been done in California to address this critical issue," Speier said,  saying that the recommendations of the Medication Errors Panel will save the lives of thousands of Californians and should be incorporated into legislation and passed by the Legislature. 

She said that since the time that the US Institute of Medicine first reported on the problem in 1999, "..."we've known about the significant harm caused by errors associated with medical treatments. At that time the focus was on errors in hospital settings which were causing an estimated 98,000 [American] deaths per year -- a number equivalent to more than four fully loaded 747 airplanes crashing every week with no survivors.," adding that a more recent data says that "....medication errors in all settings harm, injure or kill more than 1.5 million Americans every year".

Speier, a Democrat from Hillsborough (near San Francisco), who ran unsuccessfully for Lt. Governor last June, authored SCR 49 which was passed without any opposition in the Legislature in September 2005.  That resolution created a non-partisan Medication Errors Panel, to study the causes of medication error sin the outpatient setting and to recommend changes to the health care system that would reduce errors connected with prescription and over the counter drugs and other medications.  She previously authored legislation in 2000 that required certain health facilities to develop and implement a formal plan to address the issue of medication errors - though the legislation did not apply to errors done in community settings. 

Speier said in 2005 that research found that injuries resulting from medication errors are generally not the fault of any individual healthcare professional, but rather represent the failure of a complex healthcare system. She believed that some of those system failures can be prevented through new information technology  but that any reduction in medication errors requires a "variety of approaches" 

Medication Errors Panel Findings
After hearing testimony and reviewing other materials and documents the panel found that:
* Medication errors are preventable and can occur at any point in the medication use process including prescribing, transcribing, dispensing, using and monitoring.
* Medication errors are often the result of problems relating to incorrect medication use by patients (people prescribed self administered medications typically take less than half the prescribed doses according to the report).
* Low health literacy is a significant contributing factor for many medication errors (even when individuals can correctly read and repeat the instructions, "Take two tablets by mouth twice daily," many cannot accurately demonstrate the actual number of pills to be taken daily).
* Using multiple medications increases a person's risk for experiencing a medication error, especially when they are prescribed by multiple providers and filled at multiple pharmacies.

Medication Errors Panel Recommendations
* The Panel developed 12 consensus recommendations on a variety of topics that provides what the panel says "great direction for systemic change".
* Recommendations range from high-tech solutions (such as  electronic prescribing) to low-tech ideas (such as simply ensuring that the pharmacist and patient are informed of and verify a medication's intended use).
* Many other types of errors the Panel says, can also be addressed through improved consumer education about a medication's purpose, correct use, risks and benefits.
* The Panel said that the information and consultation that pharmacists provide their patients should play a critical role but that  many obstacles for pharmacists to provide consultations exist, including the lack of a payment system to cover the costs incurred while spending time educating consumers.
Note: for full list of recommendations, see full report on the CDCAN website at Medication Errors Panel - Full 27 Page Report - (PDF File)

Kim Belshe Says Report Underscores Need For Governor's Health Care Reform Proposal
California Health & Human Services Agency Secretary Kim Belshé said Tuesday (March 6) that the report  underscores the need for reducing medication errors as called for in the Governor's Health Care Reform proposal, as well as broader changes the Governor proposes to reduce all medical errors and promote patient safety.

"No one should suffer from errors in the improper prescribing, dispensing or use of medication, or suffer from unnecessary health care acquired infections," Secretary Belshé said. "For this reason, Governor Schwarzenegger's reform proposal calls for dramatic change to prevent not only medication errors, but medical errors as well."

Secretary Belshé said a 10 percent reduction in medical errors has the potential to reduce health care costs by an estimated $450 million per year.

Medications Error Panel Members
Each of the Assembly and State Senate appointees, as required by SCR 49, represent a particular group, including public health organizations, the California Medical Association, the California Retailers Association, the California Pharmacy Association, a consumer organization, the California Association of Health Plans, Consumer Healthcare Products Association, CA Society of Health Pharmacists, the Generic Pharmaceutical Association, California Nurses Association, pharmacy school faculty and the Pharmaceutical Research and Manufacturers of America. 
* State Senators:  Jackie Speier (Chair) and Sam Aanestad (Republican - Grass Valley, 4th District)
* Assemblymember: Wilma Chan (Democrat - Oakland, 16th DIstrict - now retired due to term limits) and Greg Aghazarian (Republican -  Stockton, 26th District)
* Assembly Appointees:  Dorothy Calvert, RN (Kaiser Permanente Medical Group), Robert Friis (CSUS Long Beach), John Gallapaga (AARP), Gil Preston (Watson Pharmaceuticals), Susan Ravnan (University of the Pacific), Lorie Rice (School of Pharmacy, UC San Francisco), Debbie Veale (Director, Managed Care, CVS/Pharmacy)
* State Senate Appointees: Brian Alldredge (UC San Francisco, Department of Clincial Pharmacy), Ramon Castellblanch (SF State University, Health Education Department), Carey Cotterell (Kaiser Permanente Medical Care Program), Merrill Jacobs (Pharmaaceutical Research and Manufacturers of America), Carlo Michelotti (California Pharmacists Association) and Gurbinder Sadana (Pomona Valley Hospital Medical Center, Director of Critical Care Services)

SUMMARY OF LEGISLATION RELATED TO PRESCRIPTION DRUGS
Three bills, one of which deals specifically with medication errors, are listed below that relate to prescription drugs.  One - SB 623 is not tied to medication errors - but is of interest because it calls for the state to pay for the Medicare Part D prescription drug co-payments required of certain persons with disabilities and seniors who are covered by both Medi-Cal and Medicare
 
SB 472 - PRESCRIPTION DRUGS: LABELING REQUIREMENTS
AUTHOR: State Sen. Ellen Corbett (Democrat - San Leandro, 10th District)
STATUS 02/28/07: To Senate Rules Committee for committee assignment. (Introduced in Senate 2/21/07)
CDCAN SUMMARY
Would declare the intent of the Legislature to adopt a standard format for the labeling of prescription drug containers dispensed in the State, that would include regulations for the font size of printed words on the label and the placement of information of the prescription and would provide that translated prescription drug labels should be made available to the patient if the patient's primary language is not English.
http://www.leginfo.ca.gov/pub/07-08/bill/sen/sb_0451-0500/sb_472_bill_20070221_introduced.html
BACKGROUND:
* This bill is meant to be the vehicle to carry many of the non-partisan Medication Errors Panel, chaired by former State Sen. Jackie Speier, with  recommendations, issued in a report on March 6, 2007.
* Can be heard in policy committee on or after March 24, 2007 (has not yet been referred to any committee yet, but most likely Senate Health Committee.)
PRIORITY: VERY HIGH

SB 623 - MEDI-CAL DRUG BENEFITS: COPAYMENT
AUTHOR: State Sen. Patricia Wiggins (Democrat - Santa Rosa, 2nd District)
STATUS 02/24/07: In State Senate (introduced in Senate 2/22/07)
CDCAN SUMMARY
* Would require that, beginning January 1, 2008, the Department of Health Care Services shall pay all copayments required by drug plans under the Medicare Part D Prescription Drug Program for generic or brand name medications for full-benefit dual eligible beneficiaries (those eligible for Medicare and Medi-Cal) under specified conditions.
* Would require the Department of Health Care Services to develop a process for the reimbursement of Medi-Cal enrolled pharmacies for the cost of the copayments, unless specified conditions are met.
http://www.leginfo.ca.gov/pub/07-08/bill/sen/sb_0601-0650/sb_623_bill_20070222_introduced.html
BACKGROUND
* Can be heard in policy committee on or after March 26, 2007. Has not yet been referred to any policy committee, though likely Senate Health Committee.
* This bill was not mentioned during the Medication Errors Panel press conference - nor is directly tied to the issue.  However the issue of the State paying the co-payments for medications required under Medicare Part D is an important critical issue for many persons with disabilities and seniors, and people with mental health needs and others (and once obtaining the medications, are vulnerable to the medication errors as reported by the Medication Errors Panel)
PRIORITY: VERY HIGH

AB 851  - PRESCRIPTION DRUGS: INFORMATIONAL INSERT
AUTHOR: Assemblymember Julia Brownley (Democrat - Santa Monica, 41st District)
STATUS 02/23/07: In Assembly (Introduced in Assembly 2/22/07)
CDCAN SUMMERY
Would require a pharmacist to include a large print informational insert with any dispensed prescription that poses substantial risk when taken in combination with alcohol or other medications, warning of the risks involved, as specified in this bill
http://www.leginfo.ca.gov/pub/07-08/bill/asm/ab_0851-0900/ab_851_bill_20070222_introduced.html
BACKGROUND
* More details will likely be amended into the bill.  This bill was not one of those directly referenced in the Medication Errors Panel press conference, but CDCAN is tracking this bill along with SB 472.
* Can be heard in policy committee on or after March 25 (has not yet been referred to a policy committee yet - but most likely Assembly Health Committee).
PRIORITY: HIGH (depending on more detailed amendments)

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