Safety and Risk Management Medication Error 病人安全和风险管理的用药错误课件.ppt

RPh. P.T. dispense according to established Procedures Quality related event occurs Quality Supervisor Reviews Incident Reports and near-miss documentation Quality Supervisor Reviews Quality Inservice Developed Management Kept Informed of Progress Management Reviews Policies and Adjusts PRN Quality Consult held Select and use techniques that put theory into practice. Use the techniques to catch or absorb errors. Recommit to existing policies. Develop new techniques with consensus of all stakeholders. Identify those prescription items causing problems Place colored tape on that part of the shelf-or put on different shelf To cause a second thought Reduces likelihood of prescriptions for one patient being confused with those for another patient. All items for a patient’s prescription are placed in a basket. “Two-Second Rule” No vial is left with a label and without medication for any longer than two seconds. Same for any vial with medication and without a label. Check medication label with name on sack. Check name and phone number on sack with person requesting medication. Why does my medication look different this time? Why are the directions different from those my doctor told me? Are you sure you spelled my doctor’s name correctly? If I’m allergic to aspirin can I take this? * * * David B. Brushwood, R.Ph., J.D. Professor of Pharmaceutical Outcomes and Policy The University of Florida College of Pharmacy List the challenges and opportunities for improved patient safety in pharmacy practice. Describe the operation of root cause analysis and failure mode and effects analysis. Discuss strategies for error reduction and prevention in pharmacy. List techniques that pharmacists can use to prevent medication errors. Describe the organization of pharmacy systems to manage the risk of medication errors. The media Television programs Magazines Newspapers State regulators The courts The IOM Report But… No pharmacist wants to make a mistake No pharmacy manager wants pharma