1、“Just Culture”Nicole L.Mollenkopf,Pharm.D.Medication Safety Officer for PediatricsThe Johns Hopkins HospitalSexton,et al.ISMP Medication Safety Alert.2006;11(18)1-2.Punitive CultureISMP Medication Safety Alert.2006;11(18)1-2.Blame-Free Culture赦免vs.人们人们vs.人们人们ISMP Medication Safety Alert.2006;11(18)1
2、-2.www.justculture.orgnLearning Culture nOpen,fair,and just culturenDesign safe systems nManage behavioral choices of staff www.justculture.orgwww.justculture.orgOpen,Fair,and“Just Culture”www.justculture.orgwww.justculture.orgwww.justculture.orgwww.justculture.org;ISMP Medication Safety Alert.2006;
3、11(19)1-2.www.justculture.org;ISMP Medication Safety Alert.2006;11(19)1-2.www.justculture.org;ISMP Medication Safety Alert.2006;11(19)1-2.www.justculture.org;ISMP Medication Safety Alert.2006;11(19).Vaughan 1996www.justculture.org;ISMP Medication Safety Alert.2006;11(19)1-2.www.justculture.org;ISMP
4、Medication Safety Alert.2006;11(19)1-2.Although we cannot change the human condition,we can change the conditions in which a human works.James Reason改变我们工作的环境。Gosbee LL,Burkhardt ME 2005.Carayon P,et al 2006.Carayon P,et al 2006.Gosbee LL,Burkhardt ME 2005.身体状况Gosbee LL,Burkhardt ME 2005.Gosbee LL,B
5、urkhardt ME 2005.Gosbee LL,Burkhardt ME 2005.建立标准！Gosbee LL,Burkhardt ME 2005.n英尺-烛光（FC）测量法n之前n口服溶液区35 FCn静脉区38.6 FCn之后n口服液区83 FCn静脉区78 FCn医嘱录入清单n姓名&病历号（Medical Record Number,MRN)n过敏史&体重n既往病史n是否熟悉药物？n肾/肝的剂量？n药物药物相互作用？n录入/验证医嘱n验证姓名，MRN，药物，剂量，给药途径，给药频率n标签的印刷Nicole L.Mollenkopf,Pharm.D.Medication Safet
6、y Officer for PediatricsThe Johns Hopkins HospitalDeborah R.Saine,MS,RPhMedication Safety CoordinatorWinchester Medical Centern实用性测试(Usability Testing)n简单明了的指导n例如：n统筹法表（Operational method sheet,OMS）Stroop TestnSee what you want to seenHear what you want to hearn简化、标准化、反馈机制n例如n颜色标识、部分字母大写ISMP Medication Safety Alert!Acute Care 2003;8(23):1-2.配色http:/
