Nursing core system:
①Medical advice checking system:
Medical advice should be checked on a shift-by-shift basis and in a daily total, including the order form, the execution card, and all kinds of marking (diet, level of care, allergy, isolation, etc.), and a total checking register is set up. The next shift will be responsible for checking the medical advice processed by the single-line shift. After each medical prescription is processed, it should be checked and signed. Temporary implementation of medical advice, need to be checked by a second person before execution, record the time of execution, the execution of the signature.
Resuscitation of patients issued by the physician's verbal instructions, the executor must be repeated aloud, the physician to verify the correctness of the implementation of the physician; resuscitation is complete, the physician to make up for the prescription and signature; ampoule left in the resuscitation again after checking. Questionable medical advice must be verified before implementation
② drug, injection, infusion checking system:
Drugs, injections, infusions, etc. must be strictly enforced, "three check eight to a note". Preparation of drugs to check whether the drugs in the expiration date, whether the label is clear; water, tablets, deterioration; ampoules, injection bottles have no cracks; sealing aluminum caps have no loose; infusion bottles (bags) have no leakage; liquid turbidity and flocculent, etc.. Any one does not meet the requirements shall not be used. After the preparation of drugs must be checked by a second person before implementation.
Anesthesia must be retained after the use of empty ampoules for checking, and at the same time in the drug, anesthesia drug management record book registration and signature. When using multiple drugs, attention should be paid to whether there are contraindications. When issuing drugs, injections and infusions, patients who have questions should be verified in a timely manner to confirm that there is no error before implementation. After the infusion bottle is refilled, the bed number, name, name of the main drug, and dosage should be indicated on the label, and the empty ampoule should be left behind and verified by another person before it is used.
③Transfusion checking system:
Drawing cross-matched blood checking system. When taking blood for checking system to take blood, carefully check whether the name, gender, number, transfusion quantity and blood type on the blood bag are consistent with the cross-matched blood report form to ensure accuracy. Check the expiration date and appearance of the blood to make sure it meets the standard requirements. Blood transfusion process checking system.
④Checking system for sterile articles:
Before using sterilized articles and disposable sterile articles, the packaging and containers should be checked to see if they are tight, dry and clean, and whether the date of sterilization, expiration date, and indication mark of sterilization effect meet the requirements. If you find that the items are expired, damaged packaging, unclean, wet, not up to the sterilization effect, etc., are prohibited to use. The use of sterilized items have been activated, should verify the opening time, the quality of the items, whether the packaging is tight, there is no pollution.
Disinfecting the supply room to issue disposable sterile goods records should be traceable. Records include the date of release, name, specifications, quantity, manufacturer, production lot number, sterilization date, expiration date and so on. The department designates a person to be responsible for the collection and storage of sterile articles. Regular inventory, classification and storage, timely inspection. Ensure that the product packaging is tight, clean, sterile goods without moisture, mold, expiration date.
⑤Surgical safety verification system:
Patient access to the operating room before the operating room to pick up the patient's personnel and ward nurses on duty to verify the patient's department, bed number, hospitalization number, name, gender, diagnosis, the name of the operation and the surgical site, the blood dispensing report, the preoperative medication, drug allergy test results, imaging data, etc., the surgical patients should be wearing an identification markers, and can not be brought to the valuables, Dentures, etc. can not be brought to the operating room.
Patients entering the operating room must be qualified surgeons, anesthesiologists and operating room nurses (hereinafter referred to as the three parties), respectively, before the anesthesia, before the start of surgery and before the patient leaves the operating room, **** with the patient's identity and surgical site and other contents of the verification and signature.
The verification of intraoperative medication is done by the surgeon or anesthesiologist according to the need of the situation to issue medical orders and make appropriate records, and the operating room nurse is responsible for verification. For all body cavity or deep tissue surgeries, the number of gauze pads, gauze, sutures, instruments, etc. is checked before surgery and before and after closing the body cavity to see if they match the number of preoperative pads, gauze, sutures, and instruments. Specimens removed by surgery are checked by the hand-washing nurse and the surgeon before the surgeon fills out the pathology test form and sends it for examination, and registers and hands it over.
References Baidu Encyclopedia - Nursing Technology