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State of California—Health and Human Services Agency
California Department of Public Health

AFL 09-31
August 10, 2009

All General Acute Care Hospitals and Special Hospitals

Change in Medication Error Reduction Plan (MERP) Survey Process

Since January 2009, the California Department of Public Health (CDPH) has been providing, as a courtesy, advance notice to facilities selected for a MERP survey of their upcoming 90-day survey window. Unfortunately, advance notification has become problematic in light of current State budget constraints. Therefore, CDPH is suspending advance notification of its MERP triennial surveys with reconsideration for possible reinstatement of advance notification after June 2010.

The suspension of advance notification will begin the fourth calendar quarter (October, November, and December) of 2009. CDPH will try to honor MERP survey commitments to facilities that have been notified that they are scheduled for survey during the third calendar quarter (July, August, and September) of 2009.

All Facilities Letter 08-39 dated December 9, 2008 specified that "…each facility scheduled for a survey will be provided advance notice that they will be surveyed…"

We hope you will understand that actions such as the suspension of the advance notice are sometimes necessary during financially difficult times. The surveys must continue however as Health and Safety Code 1339.63 requires as a condition of licensure that all general acute care hospitals, surgical clinics, and special hospitals adopt a formal plan to eliminate or substantially reduce medication-related errors. Section (f) of this code requires beginning January 1, 2005 CDPH "shall monitor the implementation of each facility's plan upon licensure visits". The advance notification was a courtesy initiated to preliminarily provide information which could assist the facility in gathering in advance the necessary material and multifaceted data CDPH would be requesting to review at the time of survey.

It is our mutual desire that you be successful in significantly reducing or eliminating medication errors. It, likewise, is a shared objective for you to be successful during the MERP survey process. We ask that you continue to have the following information readily accessible/available for the surveyors in order to facilitate these goals:

  • Current Medication Error Reduction Plan (MERP) with revision history dating back to 2005.
  • MERP multidisciplinary team member names, positions, locations and phone numbers.
  • Quality Assurance and Performance Improvement (QAPI) data related to medication errors and medication related sentinel events. This may include process measure information such as data compilation (include benchmarking), analysis, trending; process improvement activities, root cause analysis, failure mode and effects analysis, etc. for the last 36 months.
  • Pharmacy and Therapeutics (P&T) Committee meeting minutes and any minutes/information from any committees addressing or overseeing MERP (such as QAPI) for the last 36 months.
  • Reports, including metrics, related to medication error reduction for the last 36 months.
  • Annual reviews since the year 2005 and assessment of each of the procedures and systems listed under Health and Safety Code Section 1339.63(2)(d) with evidence of the effectiveness of each implemented procedure or modification(s) as warranted.

In our ongoing efforts to provide transparency and collaboration with providers and the public, CDPH, has launched a new email address for individuals to submit MERP related questions or comments. The new email address will provide a central point of contact where facilities and other interested parties can send emails in regards to MERP surveys and/or the MERP survey process. The email address is: Each email received will be acknowledged and the appropriate response subsequently sent by return email. Email responses from the MERP mailbox will be sent under the name "CDPH L&C MERP" unless the incoming email is forwarded for further research and specific individual response.

Please contact Loriann DeMartini, Pharm.D., Chief Pharmaceutical Consultant at (916) 552-8645 if you have questions regarding this notification.



Original Signed by Pamela Dickfoss for Kathleen Billingsley, R.N.

Kathleen Billingsley, R.N.
Deputy Director
Center for Health Care Quality

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