Pharmacies, Assisted Living, Dialysis Centers on Patient Commission’s To Do List

Rebecca “Gwen” Cox replaces the commission’s current executive director Bethany Walmsley on May 9. The outgoing leader bid farewell to her board with her perspective on “the state of the state” in patient safety -- including areas that need more attention.

Pharmacies and transitional medication management are among the next priorities of the new executive director of the Oregon Patient Safety Commission, Rebecca “Gwen” Cox, told The Lund Report.

Even though community pharmacies pay commission fees, few report adverse incidents. Of Oregon’s 715 retail pharmacies, only 16 reports have been filed this year, with just 12 reports in 2015.

Despite the low count, Maureen Ober, a pharmacist at OHSU and a commission board member representing pharmacies, is adamant about continuing to encourage reporting. “Medication safety is a huge area where there are so many errors that really affect people,” she said.

Hospital reporting of adverse incidents has improved dramatically under Walmsley’s leadership. Since 2010, those numbers grew by 167 percent, with nursing reporting showing an 804 percent spike.

The commission reviews every adverse incident report -- something no other state does which helps facilities identify the root cause of problems and improve, Walmsley told the board. Other states release only aggregate reports without any feedback on specific incidents.

Oregon also is way ahead nationally on early discussion and resolution. “Other than Iowa that just put something in place, no one else offers confidentiality” for the conversations after a serious adverse healthcare incident, Walmsley said.

Oregon’s law requires some but not all facilities to pay a fee and report incidents -- described as “mandatory pay, voluntary play.” Nursing homes fall under the statute but not the state’s 464 assisted living and residential care facilities. That would require a statute change.

The commission has also collected $30,000 from renal dialysis centers, which isn’t enough to build a $150,000 reporting tool and staff it. Two out-of-state corporate players dominate dialysis care in Oregon and share safety reports to their parent companies.

Oregon has 20 birthing centers, but has no administrative rules for them and hasn’t started collecting fees. “We have not approached this community,” Walmsley said. “We are at ground zero.”

Jan can be reached at [email protected].