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97
(adverse drug reactions,
ADRs)(medication errors)
1999(Institute of
Medicine, IOM)To Err Is Human
,000 -9,000
(medical er-
rors)
AIDS
170-290
1
Harvard Medical Practice
1
.7%
(19%)2
Joint Commission International
Center for Patient Safety2007
Patient Safety Solutions
MEDMARXThe Medication Errors
Reporting Program
(2001)(200)
THE JOURNAL OF PHARMACY24 4
20029Medication Errors
Club
11
12
200
200
-(Taiwan
Patient-safety Reporting system, TPR)
200
NCC MERP(National Co-
ordinating Council for Medication Error
Reporting and Prevention)
(wrong drug )(Im-
proper dose)(Wrong dosage
form)(Wrong time)
(Wrong technique )(Wrong
duration)(Wrong patient)
(monitoring error)
(Wrong rate)/(Wrong
strength/concentration)
(wrong route of administration)
97
(1)
(2)
()()
()
()(7)
(1)
(2)()
(1)
(2)
()()
(1)
(2)
()()
(1)
Medication Errors Club
(2)
(root cause analysis, RCA)()
()
9%%
(1)
(2)
()
nitroglycerin
()
THE JOURNAL OF PHARMACY24 4
ADR
ADR
()MgSOKC1
KPO
()Metformin
metformin
()
(7)
( )
a m i n o g l y c o s i d e s
ceftazidimeImipenemTazocin
FluconazoneAcyclovir
(9)
(10)
(11)
(12)
(1)
(1)
raloxifeneTacrolimus
2
97 7
(1)
/
(1)
(2)
()
()
()
9%
1
warfarin
//
DUE
ICU
(DUE)
DUE
(1)
THE JOURNAL OF PHARMACY24 4
(2)
()
()
()
To Err is Human
(1)
(2)
BarCode
1. Kohn LT, Corrigan JM, Donaldson
MS. Eds. To Err Is Human: Building
a Safer Health System. Washington,
DC: National Academy Press, 2000
Brennan, Troyen A.; Leape, Lucian
L.; Laird, Nan M.; et al. Incidence of
adverse events and negligence in
hospitalized patients: Results of the
Harvard Medical Practice Study I. N
Engl J Med. 2: 70-7, 1991.
2. Lesar, Timothy S.; Briceland, Laurie,
et al. Medication Prescribing Errors in
a Teaching Hospital. JAMA 2 (17):
229-2, 1990.
.
Medication Errors Club.2002..
. Krupicka MI, Bratton SL, Sonnenthal
K, et al. Impact of a pediatric clinical
pharmacist in the pediatric intensive
care unit. Crit Care Med 2002; 0:
919-21.
97 9
1. Coumadin ( warfarin ) 1 mg 2# qd X30
2.20
3. Coumadin 5 mg
1. Coumadin 1mg Coumadin 5mg2. 5mg Coumadin
200213620Coumadi n 2004
1. 5 mg
1.INR 2.
3.
1. warfarin 1MG 5MG
COUMADIN/ warfarin/
--
: Medication Errors Club
: Medication Errors Club
45 (serum creatinine: 1.2 mg/dl)
Narcaricin ...
1.2.
3.... ... ()
1. Coumadin ( warfarin ) 1 mg 2# qd X30
2.20
3. Coumadin 5 mg
1. Coumadin 1mg Coumadin 5mg2. 5mg Coumadin
200213620Coumadi n 2004
1. 5 mg
1.INR 2.
3.
1. warfarin 1MG 5MG
COUMADIN/ warfarin/
--
: Medication Errors Club
: Medication Errors Club
45 (serum creatinine: 1.2 mg/dl)
Narcaricin ...
1.2.
3.... ... ()
THE JOURNAL OF PHARMACY24 4
10
Arte la c 0.32% eye dropArte opti c 2% eye drop
: 1 2 3
0.32% Artelac 2% ArteopticMethylcelluose Carteolol Hcl:
: 1 22 33
Artelac vs Arteoptic--
: Medication Errors Club
1. 752.
3.
--
:
Arte la c 0.32% eye dropArte opti c 2% eye drop
: 1 2 3
0.32% Artelac 2% ArteopticMethylcelluose Carteolol Hcl:
: 1 22 33
Artelac vs Arteoptic--
: Medication Errors Club
1. 752.
3.
--
: