CLEAR News - Fall 2000

Doing Something About Health System Errors in Washington State
By Ron Weaver, Assistant Secretary, Washington State Dept. of Health

A look-alike drug incorrectly administered and a patient dying. A diabetic patient given a sugar-laden meal in a hospital by mistake. The wrong limb amputated, devastating the patient’s life forever. The worst examples of medical treatment gone wrong.

With the hope of moving from talk to action, the Washington State Legislature this year asked the Department of Health for recommendations on reducing medication errors in Washington State.

House Bill 2798 was originally written to require prescribers of all kinds to write legible prescriptions. Failure to do so would potentially subject the health provider to disciplinary action by the state. During the legislative process, the bill was amended to require the department to conduct a study and make recommendations.

Our final report on medication errors is due to the legislature in December. We are asked to specifically provide recommendations on:

• Increasing prescription legibility
• Minimizing confusion in prescription drug labeling and packaging
• Encouraging hospitals and health care organizations to implement proven medication safety practices, including the use of automated drug-ordering systems
• Reducing confusion created by similar-sounding drug names
• Increasing patient education on the medications they are prescribed.

To accomplish this, the department is doing several things. The recently published and much publicized Institute of Medicine (IOM) report has served as the beginning point for our discussions. In addition to our own internal research and analysis, we are holding a series of meetings with stakeholders to solicit their ideas. Through a series of site visits, we are finding the best examples of system changes that are working to reduce medication errors.

We will be asking our stakeholders questions such as:

• Should each health care facility or entity have an established medication safety program with defined executive responsibility that seriously involves the affiliated health professionals in continuous improvement of patient safety?
• How and who beyond hospitals? What is a "meaningful" program?
• What are "proven" medication safety practices?
• Should health care organizations, providers, and payors be encouraged or required to have patient safety programs? How?
• What types of incentives could be offered?
• Should there be new performance standards on patient safety? How do we build a focus on patients which is centered on systems issues versus the individual?
• How do we collaboratively establish safety performance standards for health care organizations?

After we have completed this report, we will be expanding our policy development process into the larger issue of health system errors (also known as "medical errors"). We chose that term because we believe it more accurately reflects the problem – not just medical treatment, but other health care treatments, in a variety of settings (including the home), and self-administration errors.

For this, we will use a slightly expanded IOM definition: "An error is defined as the failure of a planned action to be completed as intended or the use of a wrong plan to achieve an aim. Errors can include problems in practice, products, procedures, and systems."

We hope that our work on medication errors over the next few months will lay the foundation for a continuing dialog with stakeholders on the broader topic of reducing health system errors in Washington.

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