汉铭医院医院病安管理系统－以用药安全为例.ppt

漢銘醫院醫院病安管理系統－以用藥安全為例 簡歷 學歷： 國立交通大學運輸管理系 美國紐約州立大學 管理學院 財務管理碩士(MBA) 管理系統博士(Ph.D.) 經歷： 美國華盛頓大學醫務管理研究所　博士級講師(1991-1994) John Deere Health Care Inc. HMO 醫管顧問(1993-1994) 長庚大學 醫務管理學系所 副教授 (1994-1997) 中國醫藥大學 醫務管理學系所 主任兼所長(1997-2001) 中國醫藥大學 學術研究發展委員會 委員兼執行秘書(1999-2002) 中國醫藥大學 校務發展委員會 副主任委員兼執行秘書(2001-2002) 台灣醫務管理學會 教育研究委員會召集委員(2000-2006) 台灣醫務管理學會 常務理事(2003-2006) 大綱 前言 醫院風險/病患安全管理系統 用藥安全 結語 醫院風險病患安全管理系統 系統思維與病安 舊思維（無效） Name ? Blame ? Shame 新思維（系統） CQI ? Human Factors Engineering ? Social Engineering 系統思維新挑戰 Systems are composed of multiple, interconnected components: people, machines, processes, data. The goal of a system is to maximize the output of the system. Optimize – the performance of each of its components in order to maximize the system’s output. The output of a system has multiple dimensions. Safety, effectiveness, patient-centeredness, timeliness, efficiency, and equity. The system must optimize the level of each dimension. Optimization is a value judgment by those who design the system, who manage the system, and who use the output of the system. Most systems are open systems Complex systems are at risk of producing unintended consequences. 執行病安四個主要障礙 Donald M. Berwick Most clinicians remain blind to care-associated deaths, injuries, and near misses, because of difficulties in recognizing, tracking, and summarizing these events. A lack of appreciation of the true incidence and nature of patient injuries leads to ”unscientific theories,” which result in “counterproductive responses to the problem.” There is a lack of a business case for safety, to justify and offset the large investments that may be necessary to make care safe. Patient safety represents a difficult and complex problem. 建立醫院全面病人安全管理系統 病患安全文化問卷 Safety attitudes questionnaire- 60 items /schools/med/imed/patient_safety/surveyandtools.htm Stanford instrument- 30 items Items published in (Singer et al. 2003) Modified Stanford instrument-32 items Liane.Ginsburg@mail