2018ASHP指南_预防院内用药错误.pdf

ASHP REPORT ASHP Guidelines on Preventing Medication Errors in Hospitals Am J Health-Syst Pharm. 2018; 75: pounding, dispensing, distribution, occur.9 Blaming healthcare workers 1493-517 administration, education, monitor- involved in errors or passively encour- ing, and use.2 aging them to be more careful will not Molly Billstein-Leber, Pharm.D., prevent errors since it does not change BCPS, Drug Use Policy and Formulary The landmark Institute of Medi- the underlying conditions that con- Management, Yale New Haven Health cine (IOM) report To Err Is Human: tributed to the error. System, New Haven, CT. COL Jorge D. Carrillo, Pharm.D., Building a Safer Health System, pub- The pharmacist should participate M.S., M.P.H., BCPS, Department of lished in 1999, increased the national in multidisciplinary committees of the Pharmacy, Womack Army Medical Center, focus on improvements and the pre- organization and take an active role Fort Bragg, NC. 3 vention of errors in patient safety. in the evaluation and monitoring of Angela T. Cassano, Pharm.D., BCPS, This report drew attention to the sig- the medication-use process through- FASHP, Pharmfusion Consulting, LLC, Midlothian, VA. nificant problem of medical