California Pharmacists to Ensure Accuracy of High-Risk Patients' Admission Medication Lists

A new law in California aims to reduce errors in admission medication lists and thus make hospital care safer for patients at high risk for drug-related harm and readmission.

The law, which goes into effect on January 1, 2019, requires pharmacy staff at hospitals with more than 100 beds to obtain an accurate medication list for each newly admitted high-risk patient.

Making pharmacy responsible for reconciling these patients’ medication lists removes ambiguity from the process, said Rita Shane, chief pharmacy officer and professor of medicine at Cedars-Sinai Medical Center in Los Angeles and writer of Senate bill 1254.

A growing body of evidence shows that medication lists obtained by pharmacy staff, including trained technicians and interns, have significantly fewer errors than lists obtained through the usual means, she said. For example, a recent study found that medication lists obtained in the emergency department had at least 80% fewer errors when pharmacy personnel rather than other healthcare professionals were responsible for this function (see February 1, 2018 AJHP News).

Admission medication lists in electronic health records, including lists with errors, she said, serve as the basis for the inpatient orders that pharmacists must verify before dispensing medications.

“It doesn’t make sense that we’re verifying orders . . . based on flawed information,” Shane said.

Governor Edmund G. Brown Jr. signed the bill into law on September 22.

Not a single legislator voted against it.

First-term state senator Jeff Stone, a pharmacist, introduced the bill on February 15. It was 1 of 9 pharmacist-related pieces of legislation he submitted over the course of 2 days.

Eight of those bills got their start during a November conference call from Stone’s office in Temecula, said Danny Kudo, adjunct associate professor at Keck Graduate Institute School of Pharmacy and Health Sciences in Claremont.

The conference call took place because of a relationship that Kudo said he established with Stone a few years ago when the politician was a speaker at a California Society of Health-System Pharmacists (CSHP) meeting.

“He and I got a chance to talk and get to know each other a little bit,” Kudo said.

A longtime believer in the importance of relationships inside and outside of pharmacy, Kudo said he later described to Stone a project involving pharmacists on daily rounds, sensed interest by the senator, and invited him to Seminar 2017, a joint event of CSHP and the Nevada Society of Health-System Pharmacists held in October.

“He was quite impressed,” Kudo said.

Stone told Kudo of being interested in introducing legislation to advance pharmacy practice in California. The senator specifically mentioned scope of practice, reimbursement models, and patient safety, Kudo said.

With that conversation in mind, Kudo said, he contacted pharmacists he knew, including Shane and Steven Chen, of the University of Southern California in Los Angeles. Conference calls and a mid-December meeting in Stone’s Temecula office ensued.

“I pitched [the] concept of ensuring the accuracy of med lists,” Shane said, adding that she had found a place in the state’s pharmacy law where her idea fit in.

Kudo and Shane said Stone explained what he would need from the pharmacists and when. The California Legislature was set to reconvene on January 3.

Shane said she wrote the proposed legislation last New Year’s Eve.

Improving the accuracy of medication profiles or lists had been a personal interest for 20 years, Shane said. She had the evidence, solution, and passion.

Shane has collaborated on research regarding the accuracy of medication lists at transitions of care. During the summer, she and her team had created an infographic titled “Safe Medication Transitions: Evidence-Based Solutions.” She then accessed public databases on California residents and used a simple spreadsheet to estimate various costs—totaling millions of dollars—incurred as a result of harm associated with inaccurate medication lists.

As for the passion, it was deeply personal.

“About 20 years ago in May, my father was diagnosed with a brain tumor; it was metastatic from lung cancer,” Shane told the California Senate Committee on Business, Professions and Economic Development during its April 9 hearing. It was the first of 3 trips that she made to the state capitol in support of the bill.

After her father’s transfer to another hospital, she told the committee, “I noticed that one of the key drugs [a corticosteroid] to reduce the swelling and inflammation in his brain after a surgery was left off [the admission medication list], which was really a critical issue and I was able to get that resolved. I vowed to myself then that if I do nothing else in my career, I need to figure out [a solution] to protect patients.”

Shane had her group create a second infographic, this time to educate stakeholders in the California Hospital Association and the state board of pharmacy “as to why this is important.” She and her staff urged people to write letters. A health-system pharmacy administration resident she precepts posted the infographic as a petition on the policy-oriented website Change.org, encouraging the public to support the bill.

By the time the full senate met on May 29 to vote on the bill, which had been amended more than once, it had the official support of the California Hospital Association, the dean of the pharmacy school and the chair of the department of medicine at the University of California San Francisco, the chief executive officer of Cedars-Sinai Medical Center, and numerous other individuals.

Shane said she agreed to all the amendments, which Stone’s office shared with her.

To Shane, getting the legislature to pass a bill identifying pharmacy personnel as having ownership of medication lists or histories at hospital admission would be a critical early step in improving patient safety at transitions of care.

The California state board of pharmacy later supported the bill, as did CSHP.

When the senate voted on the amended bill from the assembly, the 2 professional groups that had earlier objected to the bill no longer did.

The bill arrived at the governor’s office on August 30.

In mid-September, a member of the governor’s staff talked with Shane to get a better understanding of the bill. Shane said she explained the importance of the bill as a patient safety initiative and finished the call with a feeling of cautious optimism.

Kudo, who was named the 2018 recipient of CSHP’s Distinguished Service Award, said in early October that his group of pharmacists and Stone’s office were ready to start considering the next set of bills.

[This news story appears in the December 15, 2018, issue of AJHP.]