Under the leadership of the Dean and the Pharmaceutical Affairs Committee, we will conscientiously implement the provisions and relevant documents of pharmaceutical affairs management. The following is a summary of the quality and safety of pharmacy in the second section. Let's have a look!
Chapter I: Section II Quality and Safety Inspection Basis of Pharmacy Department: 1. Detailed rules for the implementation of evaluation criteria for pharmacy and drug use management and continuous improvement in tertiary general hospitals (20 1 1 version).
2. 20xx Medical Quality Inspection and Assessment Standard (Monthly Assessment Index) of Pharmacy Department of Qiannan People's Hospital
On August 28th, 20xx, the quality control team of pharmacy department conducted medical quality and safety inspection on outpatient western pharmacy, emergency pharmacy, inpatient pharmacy, outpatient traditional Chinese pharmacy, western medicine warehouse and Chinese herbal pieces warehouse. The inspection results are summarized as follows:
I. General situation
1. The environment of pharmacies and warehouses is clean and tidy, the containers (racks) for displaying medicines are clean and tidy, the layout is reasonable, the medicines are classified reasonably, and the storage locations are fixed and orderly, which meets the specified requirements; The drug label specification is clear. Drugs under special management shall be stored in accordance with relevant regulations, such as narcotic drugs and psychotropic drugs of Category I in special warehouses or counters (safes), and high-risk drugs shall be stored in a centralized way, with uniform signs (white characters on black background). The temperature and humidity control equipment in the western medicine warehouse and the freezers in each pharmacy are operating normally, with daily temperature and humidity records and regular maintenance records of medicines.
2. Each department of expired drugs has relevant management system and processing flow, and timely and properly handle expired and inappropriate drugs according to the validity period and batch number of drugs. For example, the western medicine warehouse will notify all departments and pharmacies of the early warning of the near-invalid drugs, and a special person will be responsible for putting the near-invalid drugs on the shelves (with registration and early warning).
3. Randomly check the coincidence rate of each department 10 drugs, check the physical quantity of drugs on the drug shelf, and then make an account on the computer, except for the account of atropine sulfate injection (1ml/ tablet) in emergency pharmacy.
Operator (less than 12), other departments check whether the drug accounts are consistent. The management of various departments of anesthesia and psychotropic drugs conforms to relevant regulations, and all kinds of accounts, books and record books are registered in time, with complete handover records and consistent drug accounts.
4. Check the prescription review system and dispensing check system of outpatient pharmacy, emergency pharmacy and Chinese pharmacy: ① The personnel on duty can strictly implement the relevant work system and operation process of prescription dispensing, give corresponding medication instructions and guidance to patients when dispensing drugs, and patiently answer questions raised by patients. ② Randomly select 50 prescriptions from outpatient pharmacy, emergency pharmacy and traditional Chinese medicine pharmacy to check the rationality of the prescriptions. Results 1 prescription was not suitable for emergency pharmacy (inappropriate usage and dosage), 1 prescription was not suitable for outpatient pharmacy (drugs without indications), and no unreasonable prescriptions were found in Chinese pharmacy. ③ Check the dosage package of traditional Chinese medicine: check the weighing error (1 m3) of Jia Chunlong on duty, which meets the requirements (the weight difference of each dose is not more than? 5%)。
5. The staff's understanding of relevant systems, operating procedures and job responsibilities, such as asking the personnel on duty in various departments? Four checks and ten pairs? System, prescription review system, prescription deployment check system, job responsibilities, drug storage system, prescription drug suitability review content and other issues can basically be answered.
6. Check the disassembled drugs in each department: ① There is a centralized storage place, and the original packaging label of the disassembled drugs is well preserved, without moisture and mildew. ② Outpatient pharmacies, furosemide tablets (expiry date: 20xx 10 month) and adrenocortical hydrazone tablets (expiry date: 20xx 12 month) have expiry dates, and they are registered without warning signs. ③ The emergency pharmacy diethylstilbestrol tablets (expiration date: August 20xx) will expire soon, and there is no registration and warning sign. ④ No problems were found in the inpatient pharmacy.
Second, continuous improvement.
1.6 months outpatient prescription quality inspection, the qualified rate of prescriptions in July and August is only 53%.
The pass rate of outpatient prescription examination rose to 94%, and the pass rate of this examination rose to 98%( 1/50), indicating that pharmacists strengthened prescription examination and strictly implemented prescriptions? Four checks and ten pairs? The audit system and timely communication with doctors have greatly improved the quality of outpatient prescriptions, but there are still many shortcomings. The main reason is that some doctors don't pay enough attention to the standardization of prescription writing, such as doctors' irregular or incomplete diagnosis writing, especially some patients with complex causes or several diseases at the same time, who use drugs for diagnosis, and the drugs don't match the diagnosis, so it is difficult for pharmacists to check the suitability of prescription drugs; A few pharmacists are lax in examining prescriptions. When there is an unqualified prescription, the pharmacist asks the patient to find a doctor to modify it, which makes the patient feel troublesome. Some doctors complain that unreasonable prescriptions are returned to pharmacists, which leads to conflicts between doctors and patients. Therefore, to standardize prescription management and improve the level of rational drug use in hospitals requires the close cooperation and unremitting efforts of doctor Yamatonokusushi.
2. Sub-packaged drugs refer to drugs whose names, specifications, usage, dosage and expiration date cannot be clearly marked in the smallest packaging unit according to medical needs. The disassembled drugs shall be stored in the disassembling special rack (cabinet), and shall not be mixed with other drugs, and the labels of the original packaging of the disassembled drugs shall be retained. Specially assigned personnel shall regularly clean up, and timely register and handle drugs with short-term effects and warn them. When distributing medicines, please indicate the name, specification, usage, dosage and expiration date of the medicine bag as far as possible.
3. Due to the change of working hours, the outpatient pharmacy revised the handover system of narcotic drugs and psychotropic drugs of category I as needed, and improved the handover registration management; The emergency pharmacy has adjusted the placement of drugs with similar names, similar appearances and similar packaging; Poppy in traditional Chinese medicine
The pre-recorded date of shell prescription has been filled in completely; The acceptance record book of narcotic drugs and psychotropic drugs of category I and the outbound register book of western medicine warehouse have been registered in time and the records are complete.
4. At present, most Chinese herbal pieces in the warehouse are sealed (1-2kg/ bag), which is convenient for storage and maintenance, and reduces mildew, moth-eaten and moisture absorption.
5. All departments should strengthen the study of laws and regulations on pharmaceutical affairs management, relevant rules and regulations, operating procedures and job responsibilities, especially the study of Prescription Management Measures, Regulations on the Management of Narcotic Drugs and Psychotropic Drugs, Management Measures for Clinical Application of Antibacterials, and Management Specification for Hospital Prescription Review (Trial), so as to further improve the awareness rate.
Person in charge of the inspected department:
Quality control group of pharmacy department:
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Part II: Summary of Quality and Safety Work in Pharmacy Department in the Second Quarter 1. Completion of business economic indicators:
Business indicators of 182356 completed in the second quarter; Economic indicators: 29,833,635 yuan, accounting for 24.4% of the annual total. Basically the same as last quarter.
Second, work performance: continuous improvement of drug quality control
1. Drug quality management system. First of all, to ensure the implementation of the relevant system of drug acceptance, each pharmacy will conduct on-site acceptance of the received drugs, check the computer, outbound order and drug scan code, and save them to ensure that the number of drugs requested enters the inventory of each pharmacy. Warehouse staff should regularly collect port inspection reports of imported drugs, check the outbound situation of each pharmacy, and ensure that the accounts are timely and consistent.
2. Clinical pharmacists check the management and use of small medicine cabinets in each department every month, check the registration and handover of hemp essence drugs, check the quantity of drugs, check the classified storage of advanced drugs, check the validity period of drugs, analyze existing problems, urge improvement and summary, and form PDCA cycle.
3. Outpatient and inpatient pharmacy team leaders check the prepared drug batches every week, make registration, and put the drugs in order, with the recent drugs in front and the long-term drugs in the back of the shelf position to ensure that the drug batches are adjusted according to FIFO. For drugs involving batch number management, signs should be placed in front of the drugs to indicate the expiration date, so as to facilitate the verification and accurate adjustment of the drugs.
4. Drug return management system. According to the drug return management process.
5 outpatient and inpatient repackaged drugs should indicate the batch number and expiration date of the original package on the pocket.
And the date of packaging. Outpatient service and hospitalization.
6. All pharmacies record, analyze and improve dispensing errors, and form PDCA. Outpatient and inpatient pharmacies.
7. Clinical pharmacists review prescriptions, focus on the situation beyond the instructions, and report back to the medical department in time if abnormal use is found. Outpatient service and hospitalization.
8. Clinical pharmacists should publicize the instructions of newly purchased drugs and key drugs on the bulletin board, so that everyone can master the dosage, usage, proof of use and adverse reactions.
9. The use of drugs brought by patients. For example, how to ensure the safe use of self-purchased albumin blood products? . Due to the shortage of albumin, patients buy it themselves. In order to ensure the safety of drugs, it must be supported by the place of purchase and the drug quality inspection report.
10. In order to give priority to the use of the national list of essential drugs, the staff of the drug store should review the existing stocks every quarter, register the unsalable varieties and newly purchased varieties, and keep a dynamic balance.
1 1. Summarize and analyze the drug quality and safety in our hospital every quarter.
12. Each department analyzes and evaluates the implementation of quality control indicators every quarter.
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