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如何讓用藥更安全. 台大藥學系 林慧玲. Medication-Use System. 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 failure 7 systems failures  78% of the errors

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如何讓用藥更安全


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slide1

如何讓用藥更安全

台大藥學系

林慧玲

medication use system
Medication-Use System

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

systems analysis of ades
Systems Analysis of ADEs
  • 1900 ADEs/hospital/yr & 1600 potential ADEs/hospital/yr
  • proximal cause vs. underlying systems failure
  • 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
The Swiss Cheese Model

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

long term care pharmacy
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