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Hospital
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Formulary Management
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 Digital University

Digital Hospital
E- Drug system
management for Patient
Safety
High Alert
Drug Med
Reconcile &
Medication Customer E- Patient
error Experience Drug Profile
Hospital
Formulary
Management
Drug
Drug ADR & Ordering
Information Fatal Drug System
Service Interaction
 Medication error

- 100% (target > 4.3 /1000)*

- ( D-down level )

- 200% (Incidence<THIP target)

- D-I ( < 0.5

/1000 ; HAD < 0.25 /1000 )

* Seden K, Kirkham JJ, Kennedy T, et al. Cross-sectional study of prescribing errors in patients admitted to nine
hospitals across North West England.
 SIMPLE:

2012-2016
14
2556
12



10





8
( OPD IPD)
6
4
2
0
2012 2013 2014 2015 2016
IPD-Prescribing error/1000 9.463 6.303 11.684 11.161
IPD-Dispensing error/1000 0.381 0.477 0.507 0.951
IPD-Admininstration error/1000
1.24 0.974 1.111 1.172

OPD-Prescribing error/1000 1.553 1.91 3.45 3.9166
OPD-Dispensing error/1000 0.0519 0.0422 0.0932 0.0922
 Medication error Prevention (///)
- - SMI
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/ Empowerment Monitor
Action
Compliance
Train Re-check
DALI Monitor
Purpose Design (PDSA) Learning

Improve -
- - Feedback

- HA Prescribing error (/ -
- Thailand ) HAD: Warfarin
Safety goal Criteria -Re-design -IT system for Human
Evidence-based Signature Warfarin factor engineering
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Core Values : CQIT Drug Profile ()

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}

: Training & PCT&
 11
Prescribing Error

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 THIP
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} SMART ME


 Medication Administration error / 1000

D-I <0.5/1000

HAD D-I <0.25/1000

0.6
0.5
0.4 0.41 0.4 0.39 0.41
0.37 0.36 0.37
0.3
0.26 0.26
0.2
0.15 0.17
0.12 0.13 0.12
0.1 0.09 0.11 0.11 0.1

0
Jan Feb Mar Apr May Jun

2013 2014 2015 2016

 High Alert Drug ( / //)
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 17

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 9 1
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