如何讓用藥更安全台大藥學系林慧玲

Medication-Use SystemErrors re

sulted in ADEs

Intercepted

Physician prescribing 56% 48%

Transcription/verification 6% 33%

Pharmacy dispensing 4% 34%

Nurse administration 34% 0-2%

Reference: Bates et al. JAMA. 1995;274:29-34

Systems Analysis of ADEs 1900 ADEs/hospital/yr & 1600 potential ADEs

/hospital/yr proximal cause vs. underlying systems failur

e 7 systems failures 78% of the errors

Failure to disseminate drug knowledge: 29% of the errors

Inadequate patient information: 18% of the errors

Reference: Leape et al. JAMA. 1995;274:35-43

The Swiss Cheese Model

From: Reason, J. BMJ. 2000;320:768-770.

Long-term Care Pharmacy CMS (Center for Medicare and Medicaid Services) is

committed to ensuring that Medicare beneficiaries in long-term care (LTC) facilities continue to receive the medications and pharmacy services they need without interruption.

CMS continues to work with pharmacists … to provide all beneficiaries residing in LTC facilities with access to affordable prescription drug coverage enhanced compliance with treatment regimens improved health reduction of adverse health effects.

http://www.cms.hhs.gov/Pharmacy/04_ltc.asp