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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 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 • 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