Magazine article Drug Topics

State Legislatures Renew Focus on Medical Error Reports by Hospitals

Magazine article Drug Topics

State Legislatures Renew Focus on Medical Error Reports by Hospitals

Article excerpt

PROFESSIONAL PRACTICE

The death of two children at Johns Hopkins Children's Center, Baltimore, from the administration of wrong dosages of chemotherapy drugs, has stoked interest in the mandatory reporting of fatal medical errors by hospitals to regulatory authorities. The state of Maryland was already drafting such a law when the two fatalities occurred.

Maryland is only one of many states to consider such legislation. According to the National Conference of State Legislatures, at least 21 states have regulations or laws that address some aspect of reducing medical errors, including medication error reporting, with 15 having mandatory reporting and six having voluntary reporting. It is difficult to determine the actual number of states with reporting requirements because they apply to a range of healthcare facilities, such as nursing homes, hospitals, or hospices.

Originally, laws on hospital errors were drafted to protect whistle-blowers, said Kristina Lunner, director of state legislative and regulatory affairs for ASHP. Now states are starting to look at error reporting as a way of analyzing how hospital errors occur in order to increase patient safety, she said. The majority of these laws would cover any error in a hospital that leads to a patient's being harmed, not just medication or pharmacy errors.

But laws requiring error reporting are unlikely to succeed in reducing errors, according to Bruce Gordon, Pharm.D., director of medical error consulting for BD Healthcare Consulting. Also a member of the Maryland Society of Health-System Pharmacists who worked on a draft of the Maryland legislation on error reporting, Gordon believes there is enormous value in sharing stories of errors that have been made.

People have to ask themselves how and why an error occurred each time they notice an error. If a pharmacist notes that she picked up a wrong drug instead of the one she wanted, she should think about why it happened. For example, are two drugs with similar names or packaging kept too close to each other? If a computer system that updates patient locations in a hospital too slowly is leading to drugs being misdirected, does the computer system just get blamed or does it get changed? Mandatory error reporting will not make these types of analyses happen, Gordon stressed.

The major flaw in most proposed or passed laws on error reporting is that there is no protection from a report's being used in a malpractice lawsuit, Gordon observed. …

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