(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.

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(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 Section 1250.

(2)  Special hospitals, as defined in subdivision (f) of Section 1250.

(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 subdivision (d).

(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 medication-related errors.

(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 subdivision (d).

(Amended by Stats. 2003, Ch. 62, Sec. 177. Effective January 1, 2004.)