(a) (1) As a condition of licensure under this division,
every general acute care hospital, as defined in subdivision (a) of
Section 1250, special hospital, as defined in subdivision (f) of
Section 1250, and surgical clinic, as defined in paragraph (1) of
subdivision (b) of Section 1204, shall adopt a formal plan to
eliminate or substantially reduce medication-related errors. With the
exception of small and rural hospitals, as defined in Section
124840, this plan shall include technology implementation, such as,
but not limited to, computerized physician order entry or other
technology that, based upon independent, expert scientific advice and
data, has been shown effective in eliminating or substantially
reducing medication-related errors.
(2) Each facility's plan shall be provided to the State Department
of Health Services no later than January 1, 2002. Within 90 days
after submitting a plan, the department shall either approve the
plan, or return it to the facility with comments and suggestions for
improvement. The facility shall revise and resubmit the plan within
90 days after receiving it from the department. The department shall
provide final written approval within 90 days after resubmission, but
in no event later than January 1, 2003. The plan shall be
implemented on or before January 1, 2005.
(b) Any of the following facilities that is in the process of
constructing a new structure or retrofitting an existing structure
for the purposes of complying with seismic safety requirements shall
be exempt from implementing a plan by January 1, 2005:
(1) General acute care hospitals, as defined in subdivision (a) of
(2) Special hospitals, as defined in subdivision (f) of Section
(3) Surgical clinics, as defined in paragraph (1) of subdivision
(b) of Section 1204.
(c) The implementation date for facilities that are in the process
of constructing a new structure or retrofitting an existing
structure is six months after the date of completion of all
retrofitting or new construction. The exemption and new
implementation date specified in subdivision (b) and this subdivision
apply to those facilities that have construction plans and financing
for projects in place no later than July 1, 2002.
(d) For purposes of this chapter, a "medication-related error"
means any preventable medication-related event that adversely affects
a patient in a facility listed in subdivision (a), and that is
related to professional practice, or health care products,
procedures, and systems, including, but not limited to, prescribing,
prescription order communications, product labeling, packaging and
nomenclature, compounding, dispensing, distribution, administration,
education, monitoring, and use.
(e) Each facility's plan shall do the following:
(1) Evaluate, assess, and include a method to address each of the
procedures and systems listed under subdivision (d) to identify
weaknesses or deficiencies that could contribute to errors in the
administration of medication.
(2) Include an annual review to assess the effectiveness of the
implementation of each of the procedures and systems listed under
(3) Be modified as warranted when weaknesses or deficiencies are
noted to achieve the reduction of medication errors.
(4) Describe the technology to be implemented and how it is
expected to reduce medication-related errors as described in
paragraph (1) of subdivision (a).
(5) Include a system or process to proactively identify actual or
potential medication-related errors. The system or process shall
include concurrent and retrospective review of clinical care.
(6) Include a multidisciplinary process, including health care
professionals responsible for pharmaceuticals, nursing, medical, and
administration, to regularly analyze all identified actual or
potential medication-related errors and describe how the analysis
will be utilized to change current procedures and systems to reduce
(7) Include a process to incorporate external medication-related
error alerts to modify current processes and systems as appropriate.
Failure to meet this criterion shall not cause disapproval of the
initial plan submitted.
(f) Beginning January 1, 2005, the department shall monitor the
implementation of each facility's plan upon licensure visits.
(g) The department may work with the facility's health care
community to present an annual symposium to recognize the best
practices for each of the procedures and systems listed under