1. 如何讓用藥更安全 台大藥學系 林慧玲

2. Medication-Use System Errors resulted in ADEs Intercepted Physician prescribing56%48% Transcription/verification6%33% Pharmacy dispensing4%34% Nurse administration34%0-2% Reference: Bates et al. JAMA. 1995;274:29-34

3. 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

4. The Swiss Cheese Model From: Reason, J. BMJ. 2000;320:768-770.

5. 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