Abstract
We reviewed practices for the prevention of adverse drug events (ADEs) from the Making Health Care Safer (AHRQ) or interviewed to key persons of best-practice hospitals in Japan. The practices have been arranged in the order of importance or easiness for introduction with regard to relationship with the process of drug administration. Our recommendation of ADEs prevention is as follows: (1) a patient safety committee, reviewing all ADEs cases by reporting system, should be arranged in each hospital to detect defects in the process; (2) a patient safety committee analyses the task in the drug administrating process by using of Failure Mode Effect Analysis; (3) a patient safety committee should discuss (1) abolition of hand-written transcription, (2) use of consistent medical devices (infusion pumps), (3) protocols for high-risk drugs, (4) selection of look-alikeor soundlike drugs, and role of clinical pharmacists. We also hope source-marking for all drugs of Japan will be in widespread use in near future.
