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.

--

: