Medication-Use System

1
????????

• ?????
• ???

2
Medication-Use System
Errors resulted in ADEs Intercepted
Physician prescribing 56 48
Transcription/verification 6 33
Pharmacy dispensing 4 34
Nurse administration 34 0-2
Reference Bates et al. JAMA. 199527429-34
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. 199527435-43

4
The Swiss Cheese Model
From Reason, J. BMJ. 2000320768-770.
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