Article IV Medical Defects Responsible Person Blue Alert
(1), medical paperwork defects
1, outpatient (emergency) clinic physician failed to write outpatient (emergency) clinic medical records on time, or the record is incomplete.
2, not the patient does not cooperate with the diagnosis and treatment, refused to diagnose and treat or automatic forced discharge and other special circumstances recorded in the outpatient (emergency) medical records or hospitalization records.
3, did not record in the outpatient (emergency) medical records and hospitalization records of drug allergy history, blood transfusion patients did not record the history of blood transfusion.
4. Failure to complete the admission record, the first course record, the rescue record, the preoperative discussion (preoperative diagnosis), the surgical record, the anesthesia record, and other records within the specified time.
5. Failure to timely sign with the patient the various informed consent instruments prescribed by the hospital, or lack of items and paragraphs, do not fill in the time, do not sign.
6, large and medium-sized surgery without preoperative discussion, or lack of necessary auxiliary examination reports, or no preoperative summary, intraoperative precautions and postoperative observation points.
7. Inaccurate and incomplete intraoperative records, inaccurate descriptions of positive intraoperative findings, or failure to truthfully reflect accidents and blunders that occurred during the operation, or even falsification and concealment in the records.
8, the critical patients did not timely give the notice of illness to their families, or lack of records of talking to and signing with the families, or records but no signatures of the families.
9, where the decision to transfer out of the patient, the attending physician did not write a record of transfer to the department or hospital.
10, the automatic request for discharge of patients, discharge records are too simple, no discharge instructions and related precautions to account for the lack of the patient's own signature or legal representative and the superior physician's audit signature.
11, accidental deaths were not discussed and reported to the medical department or the administrative general duty on the same day.
12, cases of serious alterations, writing errors or lack of important medical content of the quality of the case connotation, or cause cases and other information missing, lost.
(2), diagnosis and treatment of nursing defects
1, outpatient (emergency) clinic physician for the patient after three visits is still difficult to clarify the diagnosis of the patient, did not ask a higher physician to review.
2, critical patients arrived at the emergency department, did not start resuscitation within three minutes.
3, outpatient (emergency) clinic physicians for critical patients did not implement the first physician responsibility system, the condition of the patient involves a number of departments, the first physician did not according to the patient's main condition admitted to the appropriate department.
4, outpatient (emergency) clinic physician did not see the patient that is issued "hospitalization certificate" or ward physician does not view the patient that is prescribed.
5, for critical patients, the consulting physician and medical technology department of the physician (technician) after receiving the invitation to consult, did not arrive at the scene within 10 minutes to examine the patient.
6, the consulting physician did not write the consultation record in accordance with the provisions of the consultation or did not examine the patient for "telephone consultation", "case consultation".
7, the third-level physician room visits are not timely or record content is not standardized.
8, the second or third line of the department duty personnel is not clear or contact communication tools are not fluent or can not be in place in a timely manner.
9, the patient's condition suddenly deteriorated and the initial treatment effect is not good, did not promptly request a higher physician consultation.
10, difficult, critical cases are not timely referred to the departmental case discussion or inter-departmental consultation.
11, the need for immediate implementation of medical advice did not explain clearly to the nurse, resulting in delayed implementation.
12, the critical patient did not do bedside double handover, or did not write the critical patient's condition, treatment matters in the handover record, or there is a omission of handover, omission of handover.
13, high-risk, high-difficulty elective surgery is not reported to the Medical Department before surgery.
14. The anesthesiologist lacks records of preoperative and postoperative anesthesia visits, or fails to examine patients within 24 hours of their return to the ward after surgery.
15, the surgeon in the postoperative period did not consult the surgical patients in a timely manner, or within three days without the third-level physician check-up records.
16, postoperative patient observation is not careful, failed to timely detect bleeding, abnormal blood seepage.
17. Inadequate preoperative preparation due to medical personnel delayed the operation.
18. Failure to implement the pre-transfusion testing and verification system, or incomplete test items, or irregularities in the signing of the informed consent.
19, the nurse did not correctly implement the medical advice or violation of the "three check seven" system.
20, wrongly issued, omitted to issue drugs, but did not cause consequences, and cause patients to complain.
21, the prescription of drugs in the wrong usage, contraindications, contraindications or dosage of drugs more than the extreme amount of unspecified, but has not yet resulted in the patient's personal damage.
22, the use of narcotic drugs, medical toxic drugs, psychotropic drugs and radioactive drugs in violation of relevant regulations.
23, take body fluid specimens, take the wrong specimen, wrong labeling, wrongly added anticoagulant, non-patient reasons for the collection of insufficient volume and the need to re-take.
24, the concept of aseptic operation is not strong, the disinfection and isolation system is not implemented or the method is not appropriate, there is a hidden danger of cross-infection of patients in the hospital.
25, late reporting, omission of infectious diseases, or in the case of serious work-related injuries, major traffic accidents, mass poisoning, etc. must be mobilized to rescue the whole hospital to rescue the patient, did not report in a timely manner.
26, due to treatment needs and the condition allows the need to transfer to the department, the transfer out of the department did not contact the transfer to the department in time or the transfer to the department without a valid reason to delay the transfer.
27, other did not cause personal injury consequences, but there are patients complaining about the treatment behavior.
(3) Defects in medical care
1. Rescue medicines and materials were not replenished and replaced in time, and there was discrepancy between accounts and materials.
2, the supply of expired items, expired sterilization instruments or substandard materials.
3, first aid equipment, equipment failure, or power supply, oxygen supply, water supply system is not regularly tested and affect the use, but did not cause consequences.
4, medical and technical departments for instruments, equipment, negligent testing and maintenance, resulting in test results distortion.
5, the medical department negligence check, the wrong specimen or project, site.
6, omission, misreporting of test results or loss of inspection request form, results report form.
7, blood, urine, stool and other tests lost specimens.
8, special test specimens, pathology specimens retained (stored) for a period shorter than the required time.
9, the results of the examination and clinical inconsistency or suspicious, did not contact with the clinical department in a timely manner and proposed to re-examination; found that the positive results outside the purpose of the examination of the initiative to report.
10, the pharmacy department failed to timely detect the prescription of drugs inappropriate use, contraindications, contraindications to the use of drugs, the dosage of more than the extreme amount.
(D), medical ethics defects
1, indifferent attitude, rude language.
2, elevated and their own, disparage others.
3, to make right and wrong, deliberately provoking conflict.
4, negligence, AWOL.
5, exaggerated efficacy and underestimation of the adverse prognosis.
6, medical staff in the process of patient consultation, surgery, medicine issuance chat, cell phone.
7, irresponsible explanation of the work of other medical staff, resulting in misunderstanding of patients or their families.
8, the emergence of other medical ethics problems.
Article V. Yellow Warning for the Person Responsible for Medical Defects
(1), failing to complete important documents such as inpatient case, first medical record, surgical record within the stipulated time, or failing to make up the record of emergency resuscitation for more than 6 hours, which may lead to a complaint of medical disputes.
(b), non-special, difficult patients, not timely diagnosis (more than 72 hours) or not timely determine and correct, supplement the treatment plan, delayed treatment resulting in patient complaints.
(3), the third-level physician room visits are not timely, especially the superior physician room visits are not timely, resulting in patient complaints.
(4), by the medical association appraisal or court judgment, although it does not constitute a medical malpractice, but there is a certain degree of negligence or error, and caused economic losses to the hospital, the amount of which is less than 10,000 yuan (10,000 yuan included).
(v), within one year, was twice medical defects blue alert.
Article VI Red Alert for the Person Responsible for Medical Defects
(1), appraised by the Medical Association or adjudicated by the People's Court as a medical malpractice.
(2), due to a variety of "inaction" factors, resulting in medical disputes, responsible for serious negligence, although not recognized as a medical incident, but the impact of bad, resulting in damage to the hospital's reputation.
(3), due to the negligence of the responsible person, resulting in medical defects, mediated by the Office of Coordination between doctors and patients, the patient with financial compensation, the amount of which exceeds 10,000 yuan.
(4), serious medical ethics events, exposed by the news media, resulting in damage to the hospital's reputation.
(v), within one year, two times by the medical defects yellow warning.
Suggested reference to the Department of Health website:/Article/ShowArticle.asp?ArticleID=940