1. Medical behavior self-examination and self-correction report Part I
I. Medical quality management
Our hospital pays close attention to the quality of service, strict prevention of medical errors, according to the law, civilized practice of medicine. The hospital set up to Zhang Jiyue, vice president of the leading group of medical quality management, regular sampling of prescriptions, medical records, timely feedback to the relevant responsible person, the whole hospital to monitor the quality of medical care. A variety of single disease quality control to meet the city and district standards.
Second, the medical instruments
Strictly abide by the "basic specification for the writing of medical records" in the requirements for patients to do objectively, truthfully, accurately, timely and complete writing of all medical instruments.
Third, the rules and regulations
Our hospital to improve and implement a series of rules and regulations, improve the management system, including the thirteen core systems, new technology access system, pharmaceutical management system, emergency public **** event management system. For patients who visit the hospital, they are required to present their medical card and ID card when registering, and hospitalized patients are required to submit a copy of both cards during hospitalization, which is carefully checked to prevent impersonation. The company's website is a great source of information about the company's products and services, and the company's website is a great source of information about the company's products and services, and the company's website is a great source of information about the company's products and services.
I strictly abide by the health insurance system, the organization of the hospital medical staff to repeatedly and seriously study the relevant policies of the health insurance, and the assessment work, the assessment results and personal interests linked to the distribution.
Fourth, the basic drug system
For the examination and treatment of patients in the clinic or hospitalized patients, the hospital is strictly in accordance with the provisions of the "Basic Drug List". Each physician is required to strictly abide by the code of ethics of practice, and effectively achieve reasonable inspection, reasonable use of medication, reasonable treatment, reasonable fees, and can use low-priced drugs do not use high-priced drugs, and effectively reduce the burden of medical costs on farmers. The stock of medicines in the pharmacy reaches more than 90% of that stipulated in the catalog. The amount of medication prescribed is strictly controlled, with no more than 3 days' worth of medication for hospitalized patients and no more than 7 days' worth of medication for discharged patients; large prescriptions, favored prescriptions, and abuse of medication are strictly prohibited, and the number of days of discharged medication shall not exceed the actual number of days of hospitalization. Strictly in accordance with the provisions of the inspection, and resolutely put an end to the phenomenon of one person's health insurance, the whole family medication.
V. Medical cost control
Our hospital in strict accordance with the provincial, municipal and district price, health, finance and other departments jointly formulated the fee standard. Pay close attention to the connotation of construction, improve service quality, shorten the average length of stay of patients, strict control of hospitalization costs.
2. Medical behavior self-examination and self-correction report Part II
In order to implement the flag Food and Drug Administration on the quality of our hospital medicines, medical equipment inspection, to protect the people to use the medical equipment safe and effective, standardize the use and management of drugs. The hospital set up a self-inspection team headed by the president, in accordance with the Xiwuqi Health Bureau issued "on the effective strengthening of the safety management of medicines and medical devices at all levels of medical institutions notice" and "Drug Administration Law" "Drug Use Quality Management Code" "standardize the standardization of pharmacy" self-check one by one, one by one, self-checking the team did a lot of detailed self-checking, self-checking the report is as follows:
First, the institution, personnel and system:
Our hospital has a "medical institutions practice license" and other legal qualifications. It has set up a drug quality management organization, which is composed of the director in charge, the person in charge of pharmacy and equipment, the person in charge of pharmacy, the person in charge of quality, and the purchaser, and clearly defines the responsibilities of all levels of personnel and institutions. At the same time, various quality management rules and regulations have been formulated as a guarantee and are seriously organized and implemented. At the same time, we have established and improved our hospital's pharmacy management committee, clinical rational use of antimicrobial drugs supervision and guidance group.
Our hospital has established a continuing education training program, focusing on the training of the "Chinese People's **** and the State Drug Administration Law", "Medical Institutions Pharmaceutical Management Regulations", "Medical Devices Supervision and Management Regulations", "Antimicrobial Drugs Clinical Application Guiding Principles", "Antimicrobial Drugs Clinical Application Management Measures", "Prescription Management Measures", "Inner Mongolia Autonomous Region 20xx Antimicrobial Drugs Clinical Application Special Rectification activities program" and other laws and regulations, ethnic drugs and medical basic theory
Theories and flag health bureau issued on strengthening the supervision and management of drugs, medical equipment, storage and preservation, the use of normative documents to improve the quality of personnel, and to further standardize the drugs, medical equipment from the purchase, acceptance into the warehouse and storage and preservation of all aspects of the use of the strict accordance with the provisions of the. The personnel engaged in the work of drugs directly in contact with the drugs every year health checkups, and establish health records to ensure that the use of drugs in the process of safety and effectiveness.
Second, the procurement and acceptance:
Strictly in accordance with the centralized purchasing system of medicines formulated by the higher health bureau for the procurement of medicines. We purchase medicines from enterprises with the qualification of drug production and operation; the acceptance of medicines in storage is carried out strictly according to the standard operation procedures, and the quality of the purchased medicines and the returned medicines after sale are checked and accepted batch by batch in strict accordance with the statutory quality standards and the quality terms of the contract.
Third, the implementation of standardized pharmacy management system:
Strictly in accordance with the standards of standardized pharmacy, the management of the hospital's Mongolian and Western pharmacy, pharmacy.
Fourth, drug storage and maintenance:
Warehouse is divided into drug warehouse, medical equipment warehouse, each warehouse are divided into qualified area, pending inspection area, unqualified area, each area in accordance with the provisions of the implementation of the color-coded management, i.e., the qualified area is green, pending inspection, the return area is yellow, the unqualified area is red. After acceptance, in strict accordance with the drug storage, maintenance system of drug storage, categorized storage, according to the drug storage conditions and requirements stored in the appropriate storage area, the drugs according to the batch number, the expiration date of centralized stacking, according to the batch number and validity of the near and far in sequence or separate stacking, the near-expiry date of the drugs fill in the expiration date of the table every month.
V. Dispensing of drugs:
Pharmacists must dispense drugs with a prescription issued by a registered medical practitioner, non-physician prescription shall not be dispensed with medicines, drug dispensing work in strict accordance with the requirements of the four checking ten pair of dispensing, the issuance of which should be followed by the "production first, first", "near-expiry first", "near-expiry first", "near-expiry first", "near-expiry first", "near-expiry first" and "near-expiry first". "Near-expiry first" and the principle of issuing according to the lot number.
VI. Adverse Reaction Monitoring:
The establishment of the Adverse Drug Reaction (ADR) monitoring and management team, the designation of full-time or part-time personnel responsible for the reporting and monitoring of ADR, the establishment and preservation of ADR monitoring files, the initiative to collect ADR, through the National Adverse Drug Reaction (NADR) monitoring and information network report, the report content should be true, complete and accurate.
VII, special drugs:
Special management of drugs with compliance with the provisions of the safe storage measures, the implementation of double double-locked, matching the account and other five special management. Purchase of special drugs should be implemented on arrival that is to check, two people to open the box, count to the smallest package, and have a special acceptance records, return, expiration, unqualified special management of drugs and waste retrieved in accordance with the provisions of the destruction of waste under the supervision of the health department, the destruction of records should be consistent with the to be.
Eight, the problems found in the inspection:
Through the self-inspection team of the hospital to use drugs in all aspects of quality management work to self-inspection, from the personnel and institutions, management system, hardware facilities, management records and other aspects of the comprehensive and detailed self-inspection, basically to achieve the use of drugs and quality management regulations, but also found some deficiencies, the drugstore, pharmacy, outpatient pharmacy, etc., involving the use of drugs and equipment, individual places, hygiene, health and safety. However, some shortcomings were also found, such as poor hygiene in the pharmacy, dispensary, outpatient pharmacy and other places involving medicines and equipment, drugs are not neatly arranged, sorting is not standardized enough, the partition is not obvious enough, and the writing records are not detailed enough, and so on. Ordered the relevant personnel in each department must be according to the system to seriously rectify, and implement to the person.
IX. Rectification:
I hospital in the self-inspection and mutual inspection on the basis of the rectification of the following problems:
1, the development of the system of confusing drugs and signs, and posted in the classification out of the confusing drugs next to.
2. The system of on-the-job education and training and the training program focusing on ethnomedicine have been developed.
3, developed a medical device purchase inspection record system.
4, developed a medical device adverse event monitoring system.
5, strengthened the care and maintenance of large medical equipment. The medical equipment inspection, maintenance and related records were made up and will be implemented for a long time.
6, strengthened the adverse reaction and medical device adverse event monitoring.
In the actual work and implementation, there may be some easily overlooked, subtle aspects of the problem, hope that the higher leadership of the work of our hospital to put forward valuable advice. In the future work, we must make persistent efforts to do a better job of our hospital's pharmacy work, to protect the people's drug safety.
3. Medical behavior self-correction report Part III
xxx year a series of medical accidents, the quality of medical care, the safety of the alarm bells ringing again. xx month in xx and xx counties, a series of two left and right indistinguishable from the medical malpractice, the former is a "right leg fracture, left leg surgery", the latter is the first one is "right leg fracture, the left leg surgery". The first one was "right leg fracture, left leg surgery", and the second one was "left side hernia, right side surgery", both patients' attending doctors were dealt with due to lack of responsibility, and the "XXX incident" occurred in XXX hospital, where the doctor concerned was found to be playing online games when the child's condition was deteriorating. The doctor concerned was found to be playing online games. In the wake of the incident, it was determined that there was a serious dereliction of duty on the part of the medical staff involved. In early 2010, CCTV reported on the death of XX medical professor XXX at Peking University First Hospital, pointing out that there were a number of irregularities in the medical treatment of several trainee doctors who were working independently of each other in the hospital.
The above events have once again sounded the alarm of medical malpractice is fiercer than a tiger, the former incident is not forgotten, the latter is the master, these events are worthy of our reference and deep thought. We are medical workers, is the white angel, the future work to have a heart of love and dedication, to have a consistent down-to-earth work. In from now on, from themselves. Also recognize the need to pay attention to the quality of medical care, I as a resident combined with their own situation is now summarized as follows:
(1) to do within 30 minutes of the patient's admission to the hospital to check and make the initial treatment.
(2) Emergency, critical and serious patients should be handled immediately and reported to the superior physician.
(3) According to the specified time to complete the medical record writing (ordinary patients 24 hours, critical patients within 6 hours; the first medical record completed on the shift, emergency patients completed before surgery).
(4) medical record writing is complete, standardized, and no missing items. One should strengthen the study of medical record writing. Correct the deficiencies. Writing is not good, to practice writing.
(5) Complete blood, urine and stool tests within 24 hours, and according to the condition of the liver, kidney function, and other required specialty tests as soon as possible.
(6) According to the specialty diagnosis and treatment routine to formulate the preliminary diagnosis and treatment plan.
(7) To manage the patient, at least once a day in the morning and afternoon rounds.
(8) Completion of medical records according to the specified time and requirements.
(9) The patient's condition should be reported to the supervisor in a timely manner.
(10) The process of diagnosis and treatment should comply with the provisions of disinfection and isolation, strict aseptic operation, to prevent the occurrence of hospital-acquired infections. If there is a case of hospital infection, fill in the form and report in time.
(11) The patient's discharge must be approved by the supervising physician, and should indicate the discharge instructions and explain the precautions.
(12) strictly according to the diagnosis and treatment routine operation, not against the health regulations. In the future, to strengthen the study of health law.
(13) Strengthen doctor-patient communication. Make your own contribution to the harmonious doctor-patient relationship.
Looking back at the past, the size of the medical incident, which is not because of paralysis or not according to the diagnosis and treatment routine operation occurred? Therefore, in the actual work to prevent the slightest step, start from the smallest thing, deal with the unsafe factors in a timely manner, to avoid the occurrence of medical. In fact, to medical safety is not difficult, the key lies in the absence of responsibility. As long as everyone is more careful, as long as the work of a little more serious and responsible attitude, in the post must do their duty, duty must be responsible, no matter where they live, as long as there is a high sense of responsibility and a strong sense of mission, will be able to avoid the occurrence of medical accidents.
4. Medical behavior self-correction report Part IV
In accordance with the instructions of the Municipal Food and Drug Administration and the provisions of the regulations, in the hospital under the organization of the leadership focused on the whole hospital medical equipment, equipment for a comprehensive inspection, the specifics of the situation are reported as follows:
First, strengthen the management, strengthen the responsibility to strengthen the quality of Awareness of responsibility
Equipped with medical device quality management personnel, engaged in medical device quality management staff with medical device-related professional knowledge, familiar with the relevant laws and regulations, able to fulfill the quality management of medical devices, effectively undertake the hospital's quality management of medical devices, guidance, supervision and the implementation of the quality management system for the inspection, rectification and continuous improvement, and to collect the quality of medical devices related. Gather information on medical device quality related laws, regulations and product quality. Laws, regulations and product quality information, implement dynamic management, and establish files, supervise the relevant departments and positions to implement the medical device regulations, rules and regulations, review the legal qualifications of medical device suppliers and medical device products, responsible for the acceptance of medical devices, procurement and maintenance and repair, inspection of the quality of medical devices, supervise the treatment of unqualified medical devices, organize the investigation and treatment of medical device quality complaints and quality accidents, organize and carry out medical device quality control and management. Complaints and quality accidents, organize and carry out the monitoring and reporting of adverse events of medical devices, and establish a quality management system covering the whole process of quality management.
Second, the procurement of medical equipment, acceptance, warehousing self-check
To ensure the quality of purchased medical equipment and the use of safety, to eliminate the entry of unqualified medical equipment, the hospital has established the "procurement of medical equipment, acceptance, warehousing management system", "large-scale equipment bidding and purchasing system", "medical equipment file management system", in accordance with the "supervision and management of the quality of use of medical equipment" provisions, re-organization of the "medical equipment quality management approach", the "quality of use of supervision and management approach". Measures", re-organized the hospital's procurement and acceptance records, and medical equipment related qualification files, and logged into the State Food and Drug Administration website to verify the registration certificate number of medical devices, to eliminate the purchase of unlicensed purchase, purchase of false certificates, purchase of certificates of no qualification, imported medical devices without Chinese manuals, Chinese labeling, Chinese labeling of the purchase of the expiration of the use of medical equipment to ensure the safe and legal use of medical equipment.
Third, the medical equipment without Chinese manuals, Chinese labeling, Chinese labeling purchase, expired use to ensure the safe and legal use of medical equipment.
Third, the medical equipment warehouse storage conditions of self-examination
In order to ensure the quality of medical devices stored in the warehouse, our hospital on the material warehouse warehouse, laboratory warehouse and the library of various departments to carry out inspections, including storage temperature, humidity and the surrounding environment is consistent with the storage conditions of the medical equipment in the warehouse. We also organize special personnel to do a good job of daily maintenance of medical equipment.
Fourth, the self-inspection of Class III medical devices (focusing on implantable medical devices)
Implantable medical devices are high-risk medical devices, in order to ensure that the people use implantable devices safety, effectiveness, the hospital has formulated the "implantable medical device purchase management system. The conditions for the purchase of medical devices and the qualifications of the supplier to make strict provisions for the implantable medical devices submitted to a series of qualifications, in accordance with relevant laws and regulations for strict examination and verification. To strengthen the information management of implantable medical devices, the establishment of a sound implantable medical device procurement, warehousing, warehousing, use, disposal and other review systems, detailed records of product information, all information into the patient's case file for management.
V. Detection and management of suspected adverse events of medical devices
To strengthen the management of unqualified medical devices, to prevent unqualified medical devices from entering the clinic, our hospital has specially formulated the "Medical Device Adverse Event Reporting System". If there is an adverse event of medical devices, the location, time, adverse reaction or basic situation of the adverse event should be investigated and recorded, and promptly reported to the supervision and management of medical devices.
VI. Self-inspection of repair, maintenance and after-sales service of medical equipment
In order to make the medical equipment in a safe state of use, as well as in line with the technical requirements of the standard, the hospital has formulated the "Medical Equipment Maintenance and Repair System", in accordance with the provisions of the production of the "Medical Equipment Repair, Maintenance and Maintenance Records", the cause of the failure of the equipment, the need to replace the spare parts, the state of the maintenance are recorded. The hospital also keeps records of the causes of malfunction, parts to be replaced and the status after repair. Our hospital also emergency medical equipment to do "first aid, life support medical equipment inspection record", requiring each department to do a good job every day to check the first aid equipment, to ensure that the equipment is in a state of readiness.
VII. Self-examination of existing problems and the need for improvement
After a period of self-examination and self-correction, the hospital's medical equipment management has become more formalized, but there are some problems, such as: the warehouse expired, unqualified medical equipment can not be destroyed in a timely manner, the library of the classification, partition placement is unreasonable, and the technicians engaged in the maintenance and repair of medical devices are not To carry out training and assessment work.
VIII, the future focus of our medical equipment
Effectively strengthen the safety of hospital medical equipment, medical equipment to prevent the occurrence of safety incidents, to ensure that the majority of patients using medical equipment safety, the future we intend to:
1, to further increase the dissemination of knowledge of the safety of medical devices, the implementation of the relevant systems, to enhance the awareness of the responsibility of the hospital safety of medical equipment.
2, increase the hospital medical device safety work daily inspection, supervision frequency, timely investigation of medical device safety hazards, firmly establish the "safety first" consciousness, regularly engaged in the maintenance of medical equipment and repair of technical personnel to carry out training and assessment work to improve the level of service.
3, continue to cooperate with the higher authorities, consolidate the achievements of the hospital medical equipment safety work, *** with the creation of a good atmosphere for medical equipment, to build a harmonious society to make greater contributions.
5. Medical behavior self-correction report Part V
According to the "supervision and management of drugs in health care institutions (trial)" requirements, our hospital in 20xx hospital drug quality management work carried out a self-check, and is now the results of the self-check report is as follows:
a. Leadership attention, management of the organization is sound.
The hospital leadership attaches great importance to the management of drugs in our hospital, set up a hospital pharmacy management team and drug therapy management team, responsible for supervising and guiding the procurement of drugs in the hospital, the approval of the work of scientific management of drugs and rational use of medicines, the Pharmacy Department is specifically responsible for the deployment of drugs, drug quality management, the establishment of a clear job responsibilities and seriously implement the various positions.
Second, strengthen the management, the establishment of a sound system of quality management of drugs and pharmacy work system.
The hospital has established and improved the Antibacterial Drug Classification Management System, Pharmacy Work System, Pharmacy Formulation Checking System, Drug Purchase Management System, Drug Maintenance Work System, Pharmacy Job Responsibilities, and a number of other management systems, through the construction of the system, the hospital's work on the management of drug quality management and the management of the work of the pharmacy has been better enhanced.
Third, strengthen the business knowledge training and learning, improve the professional quality of personnel.
The hospital organizes monthly business studies for employees to learn about pharmacy regulations and pharmacy professional knowledge, and conducts relevant assessment tests and establishes training files to further improve the professional skills and professional knowledge of the staff.
Fourth, to strengthen the management of drugs, focusing on drug quality.
Strictly implement the management regulations of the higher management departments on drug procurement, the hospital's drug procurement is through the Guangxi Zhuang Autonomous Region centralized purchasing platform for drug procurement, drug procurement directory according to the "National Essential Drugs Catalog", "Urban Health Insurance Catalog", "New Rural Cooperative Medical Essential Drugs Catalog" and the combination of the actual use of the clinic to determine and the hospital's pharmacy management team and pharmacotherapy management team review and approval by the hospital leadership. After being approved by the hospital's pharmacy management team and drug therapeutics management team and approved by the hospital leadership, the Pharmacy Department purchases the winning drugs at the winning price on the Guangxi Zhuang Autonomous Region centralized purchasing platform in accordance with the purchasing catalog. The hospital has set up a file of supplying units and strictly examined the qualifications of the supplying units and salespersons to ensure that qualified medicines are purchased from enterprises with legal qualifications
. I hospital in strict accordance with the higher health management departments and drug supervision departments of the management of the provisions of the drug business qualification from the enterprise bidding drug business enterprise Guangxi Jianyi pharmaceutical procurement purchase of medicines and equipment. Recorded the "business license" of the drug business enterprise, "drug business license", "GSP certification", the original authorization letter of the sales staff and a copy of the ID card, signed a drug quality assurance contract. According to the Drug Administration Law and relevant drug laws and regulations, and in combination with the actual situation of our hospital, we have formulated relevant drug quality management systems: including drug purchase, acceptance inspection and maintenance system, prescription allocation and prescription management system, near-expiry drug management system, special drug management system, adverse drug reaction reporting system, etc. We have also formulated a drug quality management system for the hospital, which includes a drug management system, a special drug management system, and a special drug management system. Purchased special drugs are managed in accordance with the regulations, stored in special libraries, equipped with anti-theft and monitoring facilities, and managed with double locks. Special accounts are kept, and the accounts are in line with the goods. The purchased drugs have legal tax stamps of the supplying units and detailed lists, which contain the generic names of drugs, manufacturers, batch numbers, specifications, quantities, prices, etc. The purchase and acceptance system is implemented, and the purchased drugs are inspected and accepted by two persons, and authentic and complete drug acceptance records are established. Drug acceptance records include the generic name of the drug, manufacturer, specifications, dosage form, batch number, expiration date, supply unit, quantity, price, date of purchase, date of acceptance, acceptance conclusions and other content. Purchase and acceptance records of drugs and equipment, complete records of receipt, issuer, receiver double signature is responsible for the records on file. Drugs with expiration dates of less than 6 months are warned in the management system and reported to the departments for promotion. Pharmacy, drugstore daily inspection and maintenance of drugs, once a month for drugs, medicines, mold and deterioration of the expired reported loss of reported loss work, for good reporting and approval procedures and destruction of the approved procedures, make a good record of destruction, destruction of people, supervisors double-signature, the year *** reported loss of 11 batches of expired medicines. Pharmacy, pharmacy have installed air-conditioning equipment for temperature and humidity control, refrigerator storage related to drugs, drugs can be stored in accordance with the storage requirements.
V. Strengthen the management of the pharmacy.
In accordance with the requirements of the standardized construction of the pharmacy placed drugs, regional positioning signs are obvious, internal and external drugs are stored separately, easy to string the smell of a separate storage, the daily maintenance of the drugs on display, monitoring the temperature and humidity, such as exceeding the prescribed range, and take timely measures to regulate. Qualified pharmacy technicians are responsible for reviewing and dispensing prescriptions in accordance with the law. Pharmacy technicians are responsible for reviewing, dispensing, and issuing prescriptions, as well as providing guidance on the safe use of medicines. When dispensing prescriptions, they strictly implement the "four checks and ten pairs" system to ensure the accuracy of the medicines issued. No unauthorized changes in prescriptions, questionable, contraindicated, overdose prescriptions should be refused to mix, if necessary, by the prescriber to correct or re-sign before mixing. Both the auditing and dispensing personnel sign on the prescription. Strictly implement the relevant provisions of prescription management, prescription is valid on the day of issuance, prescription drug dosage is generally not more than 7 days of dosage; emergency prescription is generally not more than 3 days of dosage; special drugs should be strictly use special prescription, drug prescription preservation for 2 years. The staff in direct contact with medicines are examined annually, and health records are established. Staff in direct contact with drugs do not suffer from infectious diseases or other diseases that may contaminate the drugs, physical health.
Six, seriously implement the adverse drug reaction monitoring and reporting system.
In 20xx, our hospital **** reported 8 cases of adverse drug reactions, 1 case of adverse drug reactions and 50 cases of drug abuse to the pharmacological supervision department.