LOS ANGELES COUNTY
DEPARTMENT OF MENTAL HEALTH
  Policy 350.02 Medication Safety Committee (306.31)
 
Policy Category:  Clinical
Distribution Level:  Directly Operated
Responsible Party:  Pharmacy
 
Approved by Curley L. Bonds, M.D., Chief Medical Officer, on Mar 06, 2023
 
I.  PURPOSE
 
This policy establishes the responsibilities and authority for Los Angeles County Department of Mental Health (DMH) Medication Safety Committee.
 
II.  DEFINITIONS
 
No definitions are associated with this policy.
 
III.  POLICY
 
Committee shall be co-chaired by Chief of Pharmacy and the designated Medical Staff member

Members of Medication Safety Committee:
  • Chief of Pharmacy (Co-chair) – (1)
  • Chief of Psychiatry or designated associate medical director psychiatrist (Co-chair) – (1)
  • Chief of Nursing or designee (permanent member) – (1)
  • Psychiatrist leadership representative designated by Chief Medical Officer (CMO) (permanent member) – (1)
  • Pharmacy Medication Safety Officer – (1)
  • Risk Management representative with either MD, RN or Pharm.D. – (2)
  • Pharmacy Supervisor – (1)
Guest(s) may be requested to join meeting by invitation depending on agenda topics
Guest(s) may include:
  • Chief Information Officer or Information Technology Leadership
  • Representative from quality improvement
 
Committee shall meet every quarter according to a pre-established schedule. Quarterly reports and recommendations shall be provided to Pharmacy and Therapeutics Committee.
 
One (1) physician, one (1) nurse from nursing leadership and one (1) pharmacist in pharmacy leadership and one (1) representative from risk management constitute a quorum.
 
Responsibilities of Medication Safety Committee:
  • Establish and promote medication safety, safe medication processes and practices for DMH.
  • Review medication and laboratory event reports, review root-cause analysis; compile and analyze statistics from departmental data on event reports.
  • Create, review and revise policies and practices in accordance with regulations, statutes and in consideration of expected practices, literature/reports in an effort to provide decisions and guidance to promote overall client and medication safety.
  • Develop and implement designs of medication workflows and medication processes that will improve medication safety, reduce incidences of medication and laboratory error(s) in clinics and in the electronic health record system.
  • Identify specific technology goals to reduce the incidences of medication errors through the use of proven technology.
  • Review and follow-up with actions for any regulatory standards and expected practices.
  • Conduct additional business meetings through special committees, conference calls, electronic mail and establishment of workgroups.
  • Communicate and disseminate educational material to clinical staff regarding pharmacy and medications.
  • Implement or facilitate implementation of corrective action(s) with DMH clinical program(s).
  • Reports to Pharmacy and Therapeutics Committee and shares data with Risk Management.
IV.  PROCEDURES
 
No procedures are associated with this policy.
 
V.  AUTHORITY
 
DMH Directive Best Practices
 
VI.  ATTACHMENTS
 
No attachments are associated with this policy.