Medical organization self-examination report

The situation is as follows. Personnel practicing grid regulatory situation

I jurisdiction of the village level medical personnel *** count 24 people, of which, 15 people in the health center, four village health center count 9 people, the health center of the existing practicing physician 1 person, practicing physician assistant 3 people, practicing nurse 1 person, b ultrasound, electrocardiography physician 1 person, the village health center, there are practicing physician assistant 2 people, rural doctors 7 people. All of the above personnel are registered to practice in my jurisdiction and filed with the City Health Bureau. Practitioners in accordance with the "Medical Practitioners Law", "rural doctors practice management regulations", "Nurses Regulations" and other laws and regulations to carry out practice activities, thus, eliminating the lack of professional qualifications to engage in the relevant diagnosis and treatment of nursing work.

II. The implementation of the rules and regulations

In accordance with the "Regulations on the Management of Medical Institutions", "Regulations on the Management of Rural Doctors", "Township Sanitation Hospitals Management Measures", "Hospital Infection Management Measures" and other laws, regulations, rules, norms and technical specifications, the establishment of sound and check the implementation of the management of the rules and regulations; to strengthen the quality of medical management and control, standardize the medical instrument It has strengthened the management and control of medical quality, standardized the writing and storage of medical documents, rationally used medicines and medical devices, ensured medical safety; strictly implemented measures for the prevention and control of hospital infections, strengthened the management of disposable medical devices and immersed diagnostic and therapeutic devices; and carried out the treatment of medical wastes and harmless treatment of wastewater and sewage in accordance with the "Regulations on the Physical Treatment of Medical Wastes" and other regulations. And strict self-examination.

III. Standardize the behavior of medical services

1, to strengthen the management and preservation of medical and nursing literature for access.

2, the rational use of essential medicines

(1) I jurisdiction of the rural and two-level medical institutions have been all the use of national provisions of essential medicines.

(2) in strict accordance with the "clinical application of antimicrobial drugs approach to the management of" the provisions of the hospital's antimicrobial drug management leading group of antimicrobial drugs in the jurisdiction of the medical institutions and prescriptions for the implementation of dynamic management of irrational use of drugs and timely intervention.

(3) a variety of charges

We strictly in accordance with the national price policy on the "management of medical service charges regulations" on all charges to implement all open system. The price is clearly labeled. The public will be able to monitor the situation.

(4) key infectious disease prevention and control

In accordance with the "Infectious Disease Prevention and Control Act" "Infectious Disease Management Regulations" relevant laws and regulations, active work, unified deployment, responsibility to a person, adhere to the first diagnosis system of responsibility for any infectious disease patients found or suspected cases, actively referral, reporting outbreaks, and actively cooperate with the higher level of control and prevention of departments to carry out the relevant flow of the transfer work. There are no cases of shirking or intercepting infectious patients. Problems

1. In the future, we should further increase the training of grassroots medical personnel, carry out education on medical quality, medical safety and medical ethics, study the laws and regulations, and carry out training on business skills and doctor-patient communication.

2, to carry out publicity and education on medical knowledge, guide the public to correctly understand the medical risks, and improve the public's awareness of medical safety and the ability to identify fake doctors and fake drugs propaganda.

3, the implementation of accountability system.

For those who do not practice according to the operating procedures in the work, medical accidents or medical disputes, in accordance with the relevant laws and regulations, serious treatment, and will not be tolerated.

Medical institutions self-examination report 4

Provincial Bureau of Hubei Province, "Hubei Province, the special inspection of Chinese medicine tablets work program" text issued, in order to further standardize the city's production of Chinese medicine tablets, business behavior, to ensure that the production and operation of Chinese medicine tablets in strict accordance with the "on strengthening the supervision and management of Chinese medicine tablets notice" (State Food and Drug Administration An [20xx] No. 25) operation, and conscientious implementation of the Provincial Bureau of the special rectification of drug safety in 20xx year Work requirements and drug production and management work plan, combined with the daily supervision of the production of traditional Chinese medicine tablets actual, our Bureau of the production of traditional Chinese medicine tablets, business behavior of the clean-up inspection, now the production of traditional Chinese medicine tablets special inspection work report is as follows:

First, the basic situation

The city's existing production of traditional Chinese medicine tablets 2 enterprises, namely, Hubei Ltd., Hubei Yisheng Pharmaceutical Co. Another Hanchuan City Light Powder Factory (production range: mercury preparations light powder, red powder), Hubei Junhui Pharmaceutical Co.

Hubei Yisheng Pharmaceutical Co., Ltd., Hanchuan City, light powder plant due to relocation, is now in the process of preparation for GMP certification, the enterprise reported by the end of this year to submit an application for GMP certification. Ltd., Hubei Shengde Tang Pharmaceutical Co., Ltd., Hubei Junhui Pharmaceutical Co., Ltd. has passed the GMP certification.

Second, the work

1, strengthen the leadership, the development of the inspection program

In order to ensure that the special inspection of traditional Chinese medicine tablets work to achieve results, I combined with the actual Xiaogan, the development of Xiaogan City, the special inspection of traditional Chinese medicine tablets work program, issued to the counties (cities.) Bureau and the relevant departments. District) Bureau and the relevant enterprises, safety supervision section, market supervision section, respectively, responsible for the production of Chinese medicine tablets, circulation of special inspection work, to further enhance awareness, unify thinking, and clarify the responsibilities of the various functional departments and the relevant responsible person.

2, the development of measures to strengthen the supervision and inspection of targeted

Through this special inspection, to further implement the "local government is responsible for the overall responsibility, the management of the department is responsible for its own, the enterprise is the first responsible person" of the drug safety responsibility system; strict implementation of the production of pharmaceuticals, business quality management standards, strict quality control, to achieve quality traceability; further implementation of the production of pharmaceuticals, management of quality standards, strict quality control, to achieve quality traceability, to achieve quality traceability. To achieve quality traceability; to further promote the construction of standardized pharmacies in medical institutions, and effectively improve the level of management of the use of traditional Chinese medicine tablets; to crack down on illegal production, sale and use of traditional Chinese medicine tablets, to ensure the quality and safety of traditional Chinese medicine tablets.

Third, check the situation

Hubei Shengdetang Pharmaceutical Co.

Hubei Shengde Tang Pharmaceutical Co., Ltd. to Chinese medicinal herbs as the starting raw materials, 20xx production of Chinese medicine tablets 102 specifications, the production of Chinese medicinal herbs basically in line with the medicinal standards, and relatively fixed origin of medicinal herbs (Dawu County real estate Chinese medicinal herbs); can be strictly enforced by the national drug standards and local Chinese medicine tablets concoctions norms, process procedures; basically to achieve compliance with the conditions of the drug GMP organization of production; production of Chinese medicines by the test, the test, the test and the test of the Chinese medicines tablets, the production of Chinese medicines tablets. The production of Chinese medicine tablets after passing the inspection, and with the goods attached to the paper inspection report; no purchased Chinese medicine tablets semi-finished products or finished products for sub-packaging or change the packaging and labeling, etc.; entrusted to test the project has been required for the record.

Four, the problem of the inspection process also found some problems

1, a few companies and employees in line with the drug GMP conditions in the organization of the production management awareness is not strong;

2, the production of traditional Chinese medicine tablets GMP management system is not strict enough to carry out;
3, a small number of companies on the quality of the Chinese herbal materials to keep watch; the local Chinese medicine preparation norms. Local Chinese medicine tablets concoction norms, process regulations are not familiar enough. On the inspection of the above problems found in the Bureau will further strengthen the publicity and supervision and order the relevant enterprises to rectify the deadline to ensure that the special inspection of traditional Chinese medicine tablets to implement, and achieve significant results.

In order to improve the quality of medical services and technical service level, my service station against the "Rules for the Implementation of the Regulations for the Administration of Medical Institutions" carried out a rigorous self-examination and self-correction work. Now the relevant self-examination report is as follows:

First, the leadership attaches importance to the strict organization

I held a meeting of the service station, the self-examination of the work of strict deployment. At the meeting, the establishment of a self-check by the head of the leading group, strictly against the "Rules for the Implementation of the Regulations for the Management of Medical Institutions" carried out a serious and detailed self-check and self-correction work, and achieved significant results.

Second, the basic situation of self-check

(a) institutional self-check: unit full name "Keyuan Street Feng Yuan Community Health Service Station", the nature of the private non-enterprise, located in; legal representative:; the main person in charge of the District Health Bureau issued a "medical institutions Practice Permit", Practice Permit No. December 23, 20xx. I service station of the "medical institutions practice license" has implemented strict management, has never been altered, sale, transfer, rent. Existing 6 beds, diagnosis and treatment subjects are preventive health care, general medicine; business room area of 320 square meters.

(b) personnel self-examination: I service station existing attending physician 1, a licensed physician, physician assistant 2 Ming, 3 nurses. My service station has never been more than the scope of registration to carry out licensing activities; never used without the qualification of licensed physicians, nurses licensed personnel or a certificate of multi-location registration of physicians engaged in medical activities, belonging to the health care personnel are licensed, and set up in the hall of the supervision column open to the public.

(C) improve the quality of service: in accordance with the relevant provisions of the health administrative departments, standards to strengthen the quality of medical management, the implementation of medical quality assurance program; regular inspection, assessment of the rules and regulations and all levels and types of personnel job responsibility system implementation and implementation, to ensure medical safety and quality of service, and constantly improve the level of service.

(D) hospital cross-infection management: the establishment of a service station within the cross-infection management leading group, composed of etc.. Frequent education and training of relevant personnel, the establishment and improvement of the management of medical waste disposal, nosocomial infection and disinfection management, waste leakage treatment program and other relevant rules and regulations, there is a person on the source of medical waste, type, quantity and so on complete records, regular disinfection of key departments and parts of the disinfection effect of the monitoring, preparation of disinfectant labels marked clear, complete and standardized.

(E) solid medical waste treatment: all medical waste is classified and collected, according to the provisions of the time of temporary storage of dirt with warning signs, dirt containers are sealed, anti-puncture, temporary storage of dirt to do the "five preventive", the transportation of medical waste transfer for the person in charge of and have a signature record.

(F) the handling of single-use medical supplies: all single-use medical supplies after use to do the soaking disinfection, destruction of the type of medical waste collected by the treatment station.

(VII) epidemic management and reporting: my service station has established a strict epidemic management and reporting system, the provisions of a person responsible for the management of the epidemic, the epidemic register is complete, the epidemic report card fill in the standardized epidemic report once a month to carry out self-checking processing, no omission or late reporting occurs.

(H) drug management self-inspection: it was found that my service station has never used fake, expired, expired and prohibited drugs. Strictly implement the provisions of the antimicrobial drug system.

Third, there are shortcomings

First, due to the lack of funding, some medical equipment can not be maintained or updated in a timely manner, to a certain extent, affecting the in-depth implementation of related business, the development of the lack of energy; second, by the establishment of the limitations of the staff, staff tension, the workload is large, the opportunity for further training to the provincial health care institutions is not much, the knowledge of the cycle of updating is long! The first is the fact that the company's business has been in a state of flux for a long time.

Fourth, the direction of future efforts

I service station must take this self-examination as an opportunity, under the leadership of the higher business management department, conscientiously implement the spirit of the meeting of the higher level, strict compliance with the "Regulations on the Management of Medical Institutions", strengthen management measures, optimize the quality of personnel, pragmatic and pioneering, and constantly improve the quality of medical services and technical service level. and technical service level.

In order to implement the County Food and Drug Administration of our hospital drugs, medical equipment quality inspection, to protect the people to use medical equipment safe and effective, standardize the use and management of drugs. The hospital set up to manage the dean as the leader of the . Self-inspection team, in accordance with the "Drug Administration Law", "Drug Use Quality Management Standard", "standardize the standards of the pharmacy" one by one self-inspection, one by one control, self-inspection team did a lot of detailed self-inspection work, self-inspection report is as follows:

A, institutions, personnel and systems:

Our hospital has a "medical institutions practice license" and other legal qualifications. The establishment of a drug quality management organization, composed of the dean in charge, the head of the pharmacy department, the head of the pharmacy, the quality of the person in charge, the buyer, clear responsibilities at all levels of personnel and institutions. At the same time, the various quality management systems that have been developed, the establishment of continuing education and training programs to improve the quality of personnel, engaged in the work of drugs directly in contact with the drugs of the personnel every year to carry out health checks and establish health records to ensure that the use of drugs in the process of safety and effectiveness.

Second, procurement and acceptance:

Strictly in accordance with the centralized purchasing system of drugs developed by the Health Bureau for the procurement of drugs. Purchase of drugs from enterprises with the qualification of drug production and operation; acceptance of drugs into the warehouse in strict accordance with the standard operating procedures, in strict accordance with the statutory quality standards and contractual quality terms of the quality of purchased drugs, after-sale return of the drugs batch by batch acceptance.

Three, the implementation of standardized pharmacy management system:

Strictly in accordance with the standards of standardized pharmacy, the hospital's pharmacy, pharmacy and outpatient department pharmacy management.

Fourth, drug storage and maintenance:

Warehouse is divided into a drug warehouse, medical equipment warehouse, each warehouse are divided into qualified area, pending inspection area, unqualified area, return area, the area in accordance with the provisions of the implementation of the color-coded management, i.e., the qualified area of the green, pending inspection, the return area of the yellow, the unqualified area of the red. After acceptance, drugs are stored in special storage and classification in strict accordance with the drug storage and maintenance system, and are stored in the corresponding storage area according to the storage conditions and requirements of the drugs, and drugs are stored separately from non-drugs, internal and external drugs, prescription drugs and non-prescription drugs, and drugs and hazardous materials that are easy to cascade odor are separated from other drugs. The drugs are stacked centrally according to batch number and expiration date, and stacked sequentially or separately according to batch number and expiration date, and the expiration date table is filled in every month for near expiration date drugs.

Fifth, the deployment of drugs:

Pharmacy staff when deploying drugs, must be with a registered medical practitioner issued by the prescription, non-physician prescription shall not be deployed drugs, drug deployment work in strict accordance with the requirements of the four checking ten pair of deployment, the issuance of the first to follow the "first produced first out of", "the near future, the first to be issued", "the first to be issued", "the first to be issued", "the first to be issued", "the first to be issued", "the first to be issued". "The first thing you need to do is to make sure that you have a good understanding of what you are doing and how you are doing it.

Six, adverse reaction monitoring:

The establishment of adverse drug reaction monitoring management team, designated full-time or part-time personnel responsible for adverse drug reaction reporting and monitoring work, the establishment and preservation of adverse drug reaction monitoring files, take the initiative to collect adverse drug reactions, through the National Adverse Drug Reaction Monitoring Information Network Reporting, report content should be true, complete and accurate. The report should be true, complete and accurate.

Specialty medicines:

Specialty medicines have safety storage measures in accordance with the provisions of the implementation of the double double locks, the account is consistent with the management of the five special. Purchase of special drugs should be carried out on arrival that inspection, double open boxes, count to the smallest package, and have a special acceptance records, return, expiration, unqualified special management of drugs and the provisions of the recovery of waste should be destroyed under the supervision of the health department, the destruction of records should be consistent with the to be.

VIII. Problems found in the inspection:

Through the self-checking team of the hospital use of drugs in all aspects of quality management work on self-checking, from the personnel organization, management system, hardware facilities, management records and other aspects of the comprehensive and detailed self-checking, basically to meet the requirements of the use of drugs and quality management regulations, but also found some However, some shortcomings were found, such as poor hygiene in individual places involving medicines such as drugstores, pharmacies and outpatient pharmacies, untidy arrangement of medicines, lack of standardized sorting, insufficiently obvious zoning, insufficiently detailed writing records and other shortcomings. Ordered the stations, groups, sections of personnel must be in accordance with the system of serious rectification, and implementation to the person.

In the actual work and implementation, there may be some easily overlooked, subtle aspects of the problem, looking to the higher leadership of the work of our hospital to put forward valuable advice. In the future work, we will certainly make persistent efforts to do a better job of our hospital's pharmacy work, to protect the people's drug safety.