PRINTER'S NO. 2547

THE GENERAL ASSEMBLY OF PENNSYLVANIA

HOUSE RESOLUTION

No.

302

Session of

2024

INTRODUCED BY GUZMAN, BURGOS, HILL-EVANS, CEPEDA-FREYTIZ,

KENYATTA, MAYES, KAZEEM, SANCHEZ, GREEN, DALEY AND POWELL,

JANUARY 31, 2024

WHEREAS, According to the National Coordinating Council for

Medication Error Reporting and Prevention, medication errors are

preventable mistakes made while prescribing or issuing

medication to a patient; and

WHEREAS, Medication errors can happen at any step in the

process of prescribing medication, including when the medicine

is prescribed, when the prescribed medication is entered into

the computer system, when the medication is dispensed or when

the medication is taken by an individual; and

WHEREAS, Medication errors may have serious consequences such

containing the medicine; and

WHEREAS, A report on the medication error incident later

found that the pharmacy technician was in fact not a technician,

but rather a certified intern and should have been supervised;

and

WHEREAS, Under current State law, pharmacists are not

required to notify the Pennsylvania Board of Pharmacy about

medication errors, but instead must notify the prescribing

doctor of a medication error within 24 hours of the error; and

WHEREAS, Since pharmacists are not required to notify a State

resulted in the death or serious harm to a patient, to the

Pennsylvania Patient Safety Reporting System (PA-PSRS); and

WHEREAS, According to the Pennsylvania Patient Safety

Authority's 2022 Annual Report, there were 257,000 reports made,

which included 247,000 reports regarding "incidents" and 10,000

reports regarding "serious events"; and

WHEREAS, The United States Food and Drug Administration (FDA)

has worked to reduce medication errors by reviewing medication

names, packaging, labeling and directions for all medications

and required barcodes to appear on some medications for the

Errors" to help reduce medication errors; and

WHEREAS, Medication errors could be further reduced with the

institution of adequate staff-to-patient ratios, so nurses and

other health care professionals are not overwhelmed with a large

number of patients and can provide better quality of care to

patients; and

WHEREAS, All Pennsylvanians would benefit from reduced

occurrences of medication errors and improved patient safety;

and

WHEREAS, The House of Representatives should craft policy

further

RESOLVED, That the study include how medication errors occur

in different settings where patients are prescribed and

administered medication, including, but not limited to, acute

care hospitals, rehabilitation centers, senior living centers,

long-term care facilities and pharmacies; and be it further

RESOLVED, That the Joint State Government Commission appoint

an advisory committee to assist in this study; and be it further

RESOLVED, That the advisory committee be composed of the

following members:

Society.

Pharmacists Association.

Nurses Association.

Advocacy Program within the Department of Health.

State Government Commission.

RESOLVED, That the study include policies adopted by other

states to reduce medication errors; and be it further

RESOLVED, That the study include best practices supported by

stakeholders such as The Hospital and Healthsystem Association

of Pennsylvania, the Pennsylvania Medical Society, the

Pennsylvania Pharmacists Association and the Pennsylvania State

Nurses Association; and be it further

RESOLVED, That the study include a review of current

Pennsylvania statute and regulations related to administration

of medicine and reporting of medication errors; and be it

RESOLVED, That the Joint State Government Commission present

its report to the House of Representatives no later than 18

months after the adoption of this resolution.