????????????????? (error) ?????????????????????(Adverse event) ???????????

1
??????
????????????????????????
2 ?????? 2551
2
????????
???????
???????
???????
????????????????? (error) ?????????????????????(Ad
verse event) ???????????
3
PTC
????????
RM
??????
IC
?????????????????????????
CLT
4
PTC (Pharmacy and Therapeutic Committee)
????????????

1. ?????????????????
2. ????????????? ???????????????????????????-???
   ??????????????????????????
3. ????????????????????????????????? ME
   ????????????????????
4. ??????????????????????? ADR ??????????????????????
   ????????

5

• ?????????? 2 ?????
• ?????????????????????? (???????)
• ????????????????????????? (??????)

6
??????/???????
1.????????????????????????

• Daily dose ????????????????????????????
• ???????? ?????????????????????????
• ?????????????????????????????????? Copy Doctor
  order ??? Drug profile
• ??????????? off ????????????????,
  ???????????????? off ??/ D/C ,Review medication
  ??? 14 ???

7
2. ????????????? ??????????

• ?????????????????????????????
• ???????????????? ?????? Double check
  ???????????? ??????????????????? (??? BD)
  ?????????????????????????????/???????
  ?????????????????????????

8
3. ???????????????????????? (Medication error)
??????

1. Prescribing error
2. Predispensing error
3. Dispensing error
4. Administration error

???????????????
A - I
9
(No Transcript)
10
(No Transcript)
11
(No Transcript)
12
??????????????? (?????????? 2551)
OPD
????? ?.?.50 ?.?.50 ?.?.50 ?.?.51
A-C 19.03 15.96 15.50 15.50 11.99
D-F 0 0 0 0 0
G-I 0 0 0 0 0
IPD
????? ?.?.50 ?.?.50 ?.?.50 ?.?.51
A-C 17.24 27.21 19.17 19.17 30.86
D-F 0 0 0 0 0
G-I 0 0 0 0 0
13
4. ???????????????????????????????????????????
(High Alert drugs)
????????

1. Atropine
2. Adrenaline
3. Aminophylline
4. Dopamine
5. Digoxin
6. KCL
7. MgSO4
8. Morphine
9. Pethidine

14
?????????????

• ???????????????/?????????
• ??????????/ ??????????
• ???????????/???????????????
• ???????????????????????????

15
Morphine injection 10 mg/ml , tab 10
mg   ???? ????__________________________________
______________????__________?? HN______________ Dx
__________________________________________________
____________________________________ ??????????
IM , IV , SC 5-10 mg/dose ??? 3-4 ??????? /
Oral 30 mg ??? 3-4 ??????? ?????????? IV
Dilute ???? Sterile water 9 ???? slowly
push 4-5 ???? ?????? Monitor 1. BP ?
???????????????? BP lt 90/60 mmHg 2.       
?????? , ??????????????? 3.        ??????????
? ???????????????? RR lt 14 ?????/???? ?
Dose ??? Monitor 5 ???? ????????????? 15
???? , 30 ???? , 1 ????????????? 4 ??????? ?
????? (????????????) 15 ???? ?????????? ??? 1
??????? ?????? 4 ???????  
  ???????????????? BP lt 90/60 mmHg ??????? RR
lt 14 ?????/???? ??????????????????????????????????
? ________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
__________________________________________________
________________________________________    
16
5. ???? Adverse drug reaction
???? Sponteneous reporting system ??????????
Naranjos Algorithm
?????????????????? ADR
???? 2548 2549 2550 2551
?????????????????????????? 16 37 13
??????????????????? 0 0 0 0 0
17

1. ???????????????????????????
2. ??????????????????????
3. ????????? ???????????????????? ???????????? ??
   chart aluminium ??? ??? Doctor order ????????????

????-???????????
????-???????????
????????????
?????????????
18
???? Intensive monitoring
??????????????????????? STS??? TEN
?????????????????????????? STS ??? TEN ??????
???????????? Cotrimoxazole ????????????? Carbam
azepine,Phenobarb, Phenytoin ????????????????
????? NVP,GPO-vir ????????????? Allopurinol
19
6. ???????????

• ????????????????????????????????????????
• ?????????????????????????????????? ??????? 1?????
  ????????????????????

20
????????? ???? 2548 2549 2550 2551
??????????????? lt1000 ??? 9,871.64 1,515.80 10,695.49 4,822.32
?????????? ? ?????? lt1 - 0.22 0.17 0.44
??????????????????? lt3 3.93 3.00 1.50 3.20
21
7. ?????????????????? (DUE)
Ceftazidime

• ?????????????????? Ceftazidime (?.?. 50-?.?.51)
  ????? 22 ???
• ??????????????????? Empirical therapy 45.45
• ????????????????????????????????????????????
  ??????? 4.55
• ???????????????? ????????????? 14
• ??????????????????????????? ??????? 10,548.06 ???

22
??????????????
Clindamycin
23
8. Drug Reconciliation
? ?????????????????????????????? Reconcile
24
??????????? 2551
Pateint safety
??????????????????????
25
?????????