First of all, it is clear that the case that the infusion set label is not attached to the medical record involves the omission of the medical record and identification.
Explain the causes and effects: This problem may be caused by negligence, human error or system defects. This omission may adversely affect the medical management and follow-up treatment of patients. The medical record without the label of perfusion device may make it difficult for medical staff to track and verify the process and effect of treatment, and increase the risk of medical accidents.
Relevant regulations and standards: the basis of supporting explanations by citing the Regulations on the Administration of Medical Institutions, the Measures for the Administration of Hospital Informatization and other relevant regulations and standards. This paper points out the requirements of marking infusion sets on medical records and the importance of identification and identification. Emphasize the importance of the accuracy and completeness of medical records to medical quality and safety.
Rectification requirements: relevant medical personnel are required to take remedial measures and update the label of the infuser in the medical record. Explain the specific rectification steps and time requirements, and ask the medical staff to recheck the label of the infuser after the rectification is completed. Emphasize the strict attitude of medical staff towards medical records and identification and the implementation of process norms.
Supervision of law enforcement: indicates that the supervision organization will follow up and supervise the rectification, and reserve the right to investigate the responsibility. At the same time, it is suggested to establish a medical safety management system and an internal audit mechanism to ensure the prevention and control of similar problems.
Cooperation and communication: express the cooperative attitude of the hospital with relevant departments and medical staff, encourage medical staff to actively reflect and communicate similar problems and suggestions, and work with * * * * to improve and enhance the quality of medical services.
Hereby,
Medical quality and safety management department (can be filled in according to the actual situation)