Part I Hospital Drug Quality Management Self-Inspection Report
According to the spirit of the relevant documents and regulations of the higher levels, our hospital immediately carried out a major inspection of the quality of medical care and made the following summary:
First, pay close attention to the quality of medical care, to ensure medical safety
1, strictly in accordance with the process and diagnosis and treatment guide to carry out clinical work to ensure the quality of medical care and medical safety.
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2, the strict implementation of the doctor's room system, and need to be in the condition of the record on the detailed record of the room: the analysis of the condition, medical treatment and the next step of the diagnosis and treatment plan record.
3, the strict implementation of the management system of practicing physicians.
4, the strict implementation of the physician duty system.
5, do a good job of "evening checkup" work. The "evening checkup" includes the newly admitted patients, critically ill patients, the results of the daytime medical treatment follow-up, the results of the analysis and processing of test results, special test results, informed consent communication (especially for patients who are going to undergo surgery or invasive tests), tomorrow's patients will be discharged from the hospital arrangements, the treatment of patients with consultation, etc. And with the physician on duty to hand over the work. And with the physician on duty to carry out the work of shift handover.
6, do a good job of shift handover. The morning shift and the afternoon shift before the end of the shift is particularly important, critical patients must be bedside shift. The physician on duty every day after the shift must be the patient's test list of the Department of a detailed review, and the abnormal results of the treatment and review.
7, the implementation of the implementation of the consultation system.
8, the department set up a special quality control inspection of medical records responsible for physicians, random sampling of medical records and do a good job of quality control, timely revision of errors and omissions.
9, for the checkup of the various feedback information, and put forward the views of the problems found in a timely manner to do a good job of rectification, to avoid making the same mistakes.
10, led by the director of the department every month, business learning, update the new knowledge and new progress in diagnosis and treatment.
11, the section of the irregular, no advance notice of the quality inspection, found that the problem, the deadline for rectification, to help implement.
12, the establishment of difficult cases consultation and discussion system, the purpose is to solve the difficult cases of diagnosis and treatment at the same time, to improve the overall academic level of each section and at the same time, the training of physicians and improve their clinical ability and level.
Second, the implementation of the system, strengthen the communication between doctors and patients to enhance the understanding of doctors and patients
1, communication is a very important link.
(1) to do a good job of communication at the time of admission: let the patient and his family to understand the patient's current condition, critical patients to the physician to explain the condition in detail, if necessary, sign the sick (critical) serious notice. To let the patient and his family to understand the name of the physician and nurse, and know the time of the communication of the condition.
(2) hospitalized communication: changes in the condition, test results, treatment programs; especially diagnosis and treatment of major changes, more timely communication. For the daytime can not come to the hospital in time to understand the condition of the patient, must be the condition of the shift to the physician on duty, so that the patient's family with the physician on duty to understand the condition.
(3) communication before discharge: the diagnosis of the disease and the results of treatment, outpatient follow-up time and the possible side effects of drugs, possible changes in the condition of the treatment method, the need to review the examination program.
(4) outpatient communication: diagnosis and treatment of the disease, the role of drugs and side effects, follow-up time.
(5) communication between doctors and nurses: the implementation of medical behavior in place in a timely manner, whether a variety of timely examination, whether changes in the patient's condition has been dealt with in a timely manner, whether there are hidden medical problems or disputes.
2, seriously implement the signing of informed consent.
For the treatment, it is necessary to communicate face-to-face with the family and the patient by the treatment personnel, the necessity of the diagnosis and examination, indications, possible risks and complications, medical costs, medical needs to be observed or treatment time to the patient's family to explain, and sign the informed consent.
3, for the existence of security risks of patients, such as critical condition, fluctuations in the condition of large changes, mental anomalies, do not cooperate with the medical operation, casually out of the patient, we must do a good job of explaining the work, and to obtain the cooperation and understanding of the patient's family, the establishment of a full-time chaperone, and do a good job of handover work.
Part II Hospital Drug Quality Management Self-inspection Report
20xx Annual Drug Quality Management Self-inspection Report According to the leadership of the Board of Pharmacy issued by the 20xx medical institutions drug safety special rectification of the work of the notification, our hospital in accordance with the Board of Pharmaceuticals training of the various contents of the self-inspection, the results of the self-inspection are summarized as follows:
First, the leadership attaches importance to a sound management organizationOur hospital set up a hospital pharmacy management and drug therapeutics committee, responsible for supervising and guiding the institution's scientific management of drugs and rational use of drugs. The Pharmacy Department set up a drug quality manager specifically responsible for the management of drug quality management, to determine the functions of each post, and establish a sound system of drug quality management of each link.
Second, the management of drugs
1, our hospital has been in July 20xx through the XXX medical institutions online centralized purchasing platform procurement of drugs, drug purchasing directory according to the "National Essential Drugs Catalog", "urban health insurance catalog", "XXX cooperative medicine basic drug catalog" and the combination of the actual use of the clinic to determine, and by the hospital's Pharmacy Management and Pharmacotherapy Committee review and approval by the Pharmacy Department. The committee reviewed and approved by the Pharmacy Department in accordance with the catalog for online procurement.
2, the establishment of the supply unit files, strict audit of the qualifications of the supply unit and sales staff. Ensure that qualified drugs are purchased from legally qualified companies.
3, according to the "Drug Administration Law" and the relevant drug laws and regulations and with the actual development of the hospital's drug quality management system: including the purchase of drugs, acceptance, maintenance system, prescription allocation and prescription management system, near-expiry drug management system, special drug management system, adverse drug reaction reporting system.
4, the purchase of anesthesia in accordance with the provisions of the management, special cabinet storage, with anti-theft facilities, the implementation of double double lock management. Special account records, accounts and goods are consistent.
5, the implementation of the validity of the drug storage management, the validity of less than six months of the drugs listed warning. Report the use of each section to promote the use.
6, the pharmacy, the drugstore daily morning, afternoon regular inspection and maintenance of drugs, temperature and humidity detection and record, such as exceeding the prescribed range, take timely control measures.
Third, the management of medical equipment
1, our hospital from the legal medical equipment enterprise supply unit to purchase medical equipment, the establishment of the supply unit file, strict audit of the qualifications of the supply unit and sales staff. Ensure that qualified medical devices are purchased from legally qualified enterprises.
2, the establishment of a complete record of the purchase and acceptance of medical equipment.
3, in accordance with the relevant requirements of the drug management in the library of medical equipment, in accordance with the requirements of maintenance and storage. Daily morning and afternoon regular inspection and maintenance of medical equipment in the warehouse, temperature and humidity testing and record, such as exceeding the prescribed range, take timely control measures.
Fourth, the management of the pharmacy
1, in accordance with the requirements of the standardization of the construction of the pharmacy placement of drugs, regional positioning signs are obvious, internal and external drugs stored separately, easy to crosstalk separate storage, storage of hazardous materials in a special cabinet.
2, in accordance with the requirements of the pharmacy on display every month for the maintenance of medicines, maintenance record ledger, daily morning and afternoon regular monitoring of temperature and humidity, and make a good record, such as exceeding the prescribed range, and take timely measures to regulate.
3, by the pharmacy professional and technical personnel to review the prescription, dispensing, dispensing and safe use of medication guidance.
4, the allocation of prescriptions strictly implement the "four check ten" system to ensure the accuracy of the drugs issued. Do not change the prescription without authorization, there are doubts, contraindications, overdose prescription should be refused to deploy, if necessary, by the prescriber to correct or re-sign before deployment. Audit and deployment of personnel should be signed on the prescription.
5, the strict implementation of the relevant provisions of prescription management, the prescription is valid on the day of issuance, special circumstances require a long period of validity, by the prescribing physician to indicate the period of validity, but the validity period shall not exceed 3 days, the dose of prescription drugs is generally no more than 7 days of dosage; emergency prescription is generally no more than 3 days of dosage; special medicines should be strictly use special prescription.
6, strictly in accordance with the provisions of the prescriptions: general prescriptions, emergency prescriptions, pediatric prescriptions saved for 1 year.
7, annual health checks for personnel in direct contact with drugs.
8, conscientiously implement the adverse drug reaction monitoring and reporting system, there are people responsible for the collection and reporting of information. Drug quality and management is a great responsibility, in the next step of management, we will take the self-inspection and self-examination as a new starting point, and carry out the following aspects of work in a solid and effective way:
(1) Strengthening the hospital and departmental management at two levels to improve the quality of drug management, to ensure the safety of medication, to ensure the safety of medical care.
(2) Establish a long-term mechanism for scientific management of drug quality in hospitals, and strictly implement drug quality management laws and regulations.
(3) Strengthen the management and use of high-risk drugs and antibacterial drugs.
(4) Strengthening the induction training for new employees and continuing education and training for old employees.
(5) Strengthen the implementation of various management systems to check the assessment and evaluation.
Part III Hospital Drug Quality Management Self-Inspection Report
In recent years, the hospital's traditional Chinese medicine in the higher departments of the strong supervision and support, our hospital with other sister hospitals committed to the development of rural traditional Chinese medicine work, rural traditional Chinese medicine as a yearly work of the top priority. According to the "xx province Chinese medicine characteristics of township health center construction standards and assessment scoresheet" and the health bureau relevant documents and instructions, our hospital efforts to strengthen the organization and leadership of rural traditional Chinese medicine work and the construction of rural traditional Chinese medicine service network, to further improve the hospital and the village health center ` basic conditions of traditional Chinese medicine construction, and systematically carry out the plan to carry out the training of traditional Chinese medicine personnel and rural doctors in traditional Chinese medicine knowledge and appropriate technology, in order to Improve the capacity and quality of Chinese medicine services in rural medical institutions.
First, attach great importance to, raise awareness
Since receiving the relevant documents and notices, our hospital attaches great importance to the hospital by the vice president of the hospital JingXiJun as leader, the president of the ZongYanJun, director of Chinese medicine GaoQingLin, director of pharmacy DuNianHe six people composed of health hospitals of traditional Chinese medicine work leading group, and many times to convene the leading group meeting, require the hospital each department and each village health room to raise the importance of the implementation of the measures to realize that To create the national rural Chinese medicine work advanced unit is more powerful to promote the development of rural Chinese medicine, better Chinese medicine culture widely promoted and popularized to benefit the people a good opportunity. We have raised awareness, unified thinking, positive response, seriously in accordance with the requirements of the district leaders at all levels to do a good job of creating.
Second, the development of programs, active
The hospital according to the "xx province Chinese medicine characteristics of township health center construction standards and assessment scoring table", "xx district to create the national rural Chinese medicine work advanced district development planning" and "the national rural Chinese medicine work advanced unit inspection and evaluation rules" developed xx central health hospital rural Chinese medicine work implementation program, integrated since 20xx Since 20xx, the rural Chinese medicine work materials and information.
Third, the results of self-examination
(a) strengthen the organizational leadership and the construction of Chinese medicine service network
Since the creation of the work carried out since the town's party and government leaders attach great importance to the work of rural traditional Chinese medicine, and take the initiative to assume the responsibility for the development of the work of traditional Chinese medicine and the task of the establishment of the leadership of the work of traditional Chinese medicine group and set up an office to formulate an annual plan for the work of traditional Chinese medicine and the implementation of the specific plan and Organize the implementation. At the same time, our hospital has also set up a leading group to create a national advanced unit for grass-roots Chinese medicine work and a Chinese medicine business steering group for rural doctors. The leading group regularly convenes special meetings to specifically study and deploy the work of Chinese medicine and solve practical problems.
(B) improve the institutional setup and facilities and equipment
Set up the establishment of Chinese medicine department, our hospital in October 20xx newly set up a Chinese medicine hall, in the decoration fully embodies the characteristics of the Chinese medicine culture, and the formation of relatively independent of the Chinese medicine integrated service area, which set up a Chinese medicine diagnosis and treatment room, a Chinese medicine treatment room, a traction room, an acupuncture physiotherapy room. There is a traditional Chinese medicine pharmacy, which is equipped with Chinese medicine cupboards (hoppers), medicine cupboards, mixing tables, medicine arbiters, standard sieves and decocting machines, etc. The hospital is now equipped with 280 kinds of traditional Chinese medicine tablets and 85 kinds of proprietary Chinese medicines, and is able to provide decocting services for patients. In order to better promote the appropriate technology of Chinese medicine and carry out the business of Chinese medicine more widely, the Health Bureau has equipped the hospital with a number of basic facilities and diagnostic and therapeutic equipments suitable for carrying out the business of Chinese medicine, including acupuncture and moxibustion treatment beds, tui-na treatment beds, TDP lamps, electro-acupuncture therapeutic instrument, wax therapeutic instrument, cervical and lumbar spine traction beds, and purchased acupuncture and moxibustion equipments, fire pots, Gua Sha oil, Gua Sha boards, pure moxa strips, intermediate frequency therapeutic instruments and moxibustion boxes. The equipment.
(C) actively promote appropriate technology, a wide range of Chinese medicine business
Our doctors of traditional Chinese medicine in accordance with the "simple, convenient, tested, inexpensive," the principle of the use of acupuncture, moxibustion, tuina, cupping, plastering, gua sha, fumigation, acupoint injections, wax therapy, bloodletting therapy, traction and other 11 kinds of Chinese medicine appropriate technology to carry out diagnosis and treatment of a variety of common diseases. The clinic provides diagnosis and treatment for a variety of common diseases. Among them, the number of Chinese medicine outpatient and emergency visits accounted for 34% of the total number of outpatient and emergency visits; Chinese medicine revenue accounted for 35% of the total drug revenue, Chinese medicine revenue accounted for 33% of the total business income, Chinese medicine prescription writing qualification rate of more than 95%; Chinese medicine outpatient medical records have not been implemented.
In terms of drug management and use, our hospital strictly implements the national basic drug system, strictly manages the use of Chinese medicine tablets and proprietary Chinese medicines, and strictly implements the relevant standards and norms of Chinese medicine.
In terms of carrying out TCM body quality identification services, health guidance is carried out according to the different body qualities of the residents and recorded in the residents' health records. However, due to the lack of publicity of the basic knowledge of Chinese medicine, so that the work in this area almost stopped, and now our hospital has actively taken the corresponding measures to solve the problem.
In the development of Chinese medicine rehabilitation services, our hospital is basically able to apply the traditional means of rehabilitation of Chinese medicine, combined with modern physiotherapy methods, for neck, shoulder, lumbar and leg pain, after-effects of stroke and other diseases for rehabilitation treatment.
(D) carry out health education, popularization of knowledge of Chinese medicine
Health education is one of the basic public **** health service projects determined by the state, health education plays an important role in improving the health literacy of the general public, advocating a healthy lifestyle, preventing and controlling infectious diseases and chronic diseases. In order to better implement the health education work, our hospital actively produces health education materials on Chinese medicine, including textual materials focusing on the contents of Chinese medicine, and sets up publicity columns for popularization and education. Developed knowledge of Chinese medicine popularization education plan, carry out public health Chinese medicine consultation, guide rural residents to understand the Chinese medicine health care knowledge and methods.
(E) strengthen business training and further study
In order to meet the needs of the development of Chinese medicine work in my township, I sent a Chinese medicine professionals in Dingxi City Hospital of Traditional Chinese Medicine for further study of acupuncture and physiotherapy. According to the requirements of the relevant documents and hospital business needs, our hospital organization senior physician to the new personnel and the village health office of Chinese medicine practitioners to focus on business training and learning, and achieved certain results.
Fourth, the main problems and difficulties
Through this self-examination work, our hospital in rural Chinese medicine work there are still many problems and difficulties.
(a) Insufficient Chinese medicine tablets, some Chinese medicines have been in stock for too long and are of poor quality.
(ii) outpatient medical record writing has not been carried out, and there are few hospitalized patients in the Chinese medicine department.
(3) In terms of the development of appropriate technology in Chinese medicine, due to limited conditions or immature technology, technologies such as acupressure and drug fumigation have not been carried out so far. Other technologies have been widely carried out, but the standardization has to be strengthened.
(d) in the overall decoration of the Chinese medicine service area has taken certain measures, but still does not meet the requirements, has not yet formed an ancient, simple and natural Chinese medicine cultural atmosphere.
(E) the popularization of knowledge of Chinese medicine, education, the depth of efforts to be strengthened, this work has not been y rooted in the people, coupled with the busy season residents have no time to take care of, so that the Chinese medicine qualitative identification services, Chinese medicine health education, special populations of Chinese medicine health care and other work to be carried out by the restrictions.
Fifth, the next step in the work of the idea
First, actively strive for funds for the cause, to provide economic security for the work of Chinese medicine; second is to continue to focus on the work of rural Chinese medicine as a key work, strengthen the supervision and implementation of the coordination of all aspects of the relationship between the gradual completion of the indicators, and to promote the progress of the work in a comprehensive manner; third is to further standardize the technical operation of the practitioners of the relevant professions of Chinese medicine, retraining, retraining, learning, retraining, retraining. The third is to further standardize various technical operations, the practitioners of Chinese medicine-related professions retraining, learning and study, in order to improve the quality and level of Chinese medicine services.