HR 203 — A Resolution directing the Joint State Government Commission to conduct a study of reported patient safety events and issue a report with recommendations for reducing reportable patient safety events and improving patient safety.

PRINTER'S NO.   1458

                  THE GENERAL ASSEMBLY OF PENNSYLVANIA



           HOUSE RESOLUTION
              No. 203
                                              Session of
                                                2025

     INTRODUCED BY GUZMAN, HILL-EVANS, SANCHEZ, RIVERA AND CEPEDA-
        FREYTIZ, APRIL 22, 2025

     REFERRED TO COMMITTEE ON HEALTH, APRIL 22, 2025


                               A RESOLUTION
 1   Directing the Joint State Government Commission to conduct a
 2      study of medication errors and issue a report to provide
 3      recommendations on reduction of errors and improved patient
 4      safety.
 5      WHEREAS, According to the National Coordinating Council for
 6   Medication Error Reporting and Prevention, medication errors are
 7   preventable mistakes made while prescribing or issuing
 8   medication to a patient; and
 9      WHEREAS, Medication errors can happen at any step in the
10   process of prescribing medication, including when the medicine
11   is prescribed, when the prescribed medication is entered into
12   the computer system, when the medication is dispensed or when
13   the medication is taken by an individual; and
14      WHEREAS, Medication errors may have serious consequences such
15   as death, hospitalization, disability or birth defects; and
16      WHEREAS, Didier Epopa, a patient at Mercy Fitzgerald Hospital
17   in Darby, Delaware County, was issued the wrong medication,
18   which caused his body to seize and muscles to tighten; and
19      WHEREAS, The error occurred because a pharmacy technician at
 1   Mercy Fitzgerald Hospital wrongly labeled the intravenous bag
 2   containing the medicine; and
 3         WHEREAS, A report on the medication error incident later
 4   found that the pharmacy technician was in fact not a technician,
 5   but rather a certified intern and should have been supervised;
 6   and
 7         WHEREAS, Under current State law, pharmacists are not
 8   required to notify the Pennsylvania Board of Pharmacy about
 9   medication errors, but instead must notify the prescribing
10   doctor of a medication error within 24 hours of the error; and
11         WHEREAS, Since pharmacists are not required to notify a State
12   agency, many times this leads the hospital to only conduct an
13   internal investigation of the error rather than involving the
14   Department of Health; and
15         WHEREAS, Hospitals are required to report "serious events,"
16   which are instances that result in death or serious harm to a
17   patient, and "incidents," which are events that could have
18   resulted in the death or serious harm to a patient, to the
19   Pennsylvania Patient Safety Reporting System; and
20         WHEREAS, According to the Pennsylvania Patient Safety
21   Authority's 2022 Annual Report, there were 257,000 reports made,
22   which included 247,000 reports regarding "incidents" and 10,000
23   reports regarding "serious events"; and
24         WHEREAS, The United States Food and Drug Administration (FDA)
25   has worked to reduce medication errors by reviewing medication
26   names, packaging, labeling and directions for all medications
27   and required barcodes to appear on some medications for the
28   purpose of ensuring the correct strength and type of medication;
29   and
30         WHEREAS, The FDA also released a guidance in 2016 titled

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 1   "Safety Considerations for Product Design to Minimize Medication
 2   Errors" to help reduce medication errors; and
 3         WHEREAS, Medication errors could be further reduced with the
 4   institution of adequate staff-to-patient ratios, so nurses and
 5   other health care professionals are not overwhelmed with a large
 6   number of patients and can provide better quality of care to
 7   patients; and
 8         WHEREAS, All Pennsylvanians would benefit from reduced
 9   occurrences of medication errors and improved patient safety;
10   and
11         WHEREAS, The House of Representatives should craft policy
12   informed by a thorough understanding of how to reduce medication
13   errors and improve patient safety; therefore be it
14         RESOLVED, That the House of Representatives direct the Joint
15   State Government Commission to conduct a study of medication
16   errors and issue a report to provide recommendations on
17   reduction of errors and improved patient safety; and be it
18   further
19         RESOLVED, That the study include how medication errors occur
20   in different settings where patients are prescribed and
21   administered medication, including acute care hospitals,
22   rehabilitation centers, senior living centers, long-term care
23   facilities and pharmacies; and be it further
24         RESOLVED, That the Joint State Government Commission appoint
25   an advisory committee to assist in this study; and be it further
26         RESOLVED, That the advisory committee be composed of the
27   following members:
28             (1)   The Secretary of Health or a designee.
29             (2)   One individual representing The Hospital and
30         Healthsystem Association of Pennsylvania.

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 1             (3)    One individual representing the Pennsylvania Medical
 2      Society.
 3             (4)    One individual representing the Pennsylvania
 4      Pharmacists Association.
 5             (5)    One individual representing Pennsylvania State
 6      Nurses Association.
 7             (6)    One individual from the Pennsylvania Patient
 8      Advocacy Program within the Department of Health.
 9             (7)    One licensed pharmacist to be selected by the Joint
10      State Government Commission.
11             (8)    One licensed registered nurse to be selected by the
12      Joint State Government Commission.
13             (9)    One licensed physician to be selected by the Joint
14      State Government Commission.
15             (10)    Any other member identified as being helpful by the
16      Joint State Government Commission;
17   and be it further
18      RESOLVED, That the study include policies adopted by other
19   states to reduce medication errors; and be it further
20      RESOLVED, That the study include best practices supported by
21   stakeholders such as The Hospital and Healthsystem Association
22   of Pennsylvania, the Pennsylvania Medical Society, the
23   Pennsylvania Pharmacists Association and the Pennsylvania State
24   Nurses Association; and be it further
25      RESOLVED, That the study include a review of current
26   Pennsylvania statute and regulations related to administration
27   of medicine and reporting of medication errors; and be it
28   further
29      RESOLVED, That the study include a review of the agency in
30   the Commonwealth with regulatory oversight of medication errors;

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1   and be it further
2      RESOLVED, That the Joint State Government Commission present
3   its report to the House of Representatives no later than 18
4   months after the adoption of this resolution.




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