(A) checking system
1, medical advice checking system
1), medical advice by two people to check the correctness of the implementation of the medical advice must be checked once a day total checking medical advice.
2) The date, time and signature must be written and checked by another person. Both the transcriber and the checker must sign.
3), the temporary implementation of medical advice, need to be checked by a second person, can be implemented, and record the time of implementation, the implementation of the signature of the person.
4), rescue the patient, the physician issued a verbal medical advice, the executor must be repeated aloud, and then executed, the rescue is complete, the doctor to make up for the medical advice and signature. The ampoule is left to be checked again after resuscitation.
5), there are doubts about the medical advice must be asked clearly before the implementation and transcription.
2, medication, injection, infusion checking system
1), medication, injection, infusion must be strictly enforced before the "three checks and seven". Three checks: check after setting up the drug; medication, injection, disposal before the check; injection, disposal after the check. Seven pairs: bed number, name, drug name, dose, concentration, time, usage.
2), before the preparation of drugs to check the quality of drugs, water, tablets, pay attention to whether there is no deterioration, ampoule, injection bottle with or without cracks; sealing the aluminum cap with or without loosening; infusion bag with or without leakage; medicine with or without turbidity and flocculent. Expired drugs, expiration date and batch number such as non-compliance or unclear labeling shall not be used.
3), after setting the medicine must be checked by a second person before execution.
4), allergy-prone drugs, should be asked before the administration of allergy history; the use of poison, anesthesia, psychotropic drugs, strict implementation of the "medical institutions, narcotic drugs, psychotropic drugs of the first category of the management regulations" (Wei medicine [2005] No. 438 document). Nurses should go through repeated checking and return the ampoule to the pharmacy in time after use; when giving multiple drugs, attention should be paid to whether there are any contraindications for compounding. At the same time, the Nursing Department should standardize and improve the operation guidelines for skin test drugs and the table of contraindications of drugs according to the instructions of drugs.
5), the issue of drugs, injections, patients, such as questions, should be checked in a timely manner, checking the error before implementation.
6), infusion bottles after the addition of drugs to indicate the name of the drug on the label, the dose, and leave the ampoule, checked by another person before use.
7), the strict implementation of the bedside double checking system.
3, surgical patient checking system
1), the operating room to pick up the patient, should check the department, hospitalization number, bed number, name, wristband, gender, age, diagnosis, the name of the operation and the part of the site (left and right) and its signs, preoperative medication, blood transfusion of the eight pre-transfusion results, the results of drug allergy test and the surgical notification form is consistent with the operation of the medicines, items brought by surgical medical advice (such as cT, x-ray film). radiographs). Assess the patient's overall condition and skin condition, and ask about allergy history.
2) The surgical nurse checked whether the surgical instruments were complete, and whether the categories, specifications, and quality of various supplies were in order. The patient's body position is correct, as far as possible to expose the surgical field and to prevent the occurrence of falling out of bed and pressure ulcers.
3), the surgical staff before surgery again check the department, hospital number, bed number, name, wristband, gender, age, diagnosis, surgical site, anesthesia and medication, blood dispensing report. When the hand-washing nurse opens the sterile bag, check whether the chemical index card in the bag is up to standard. Where the body cavity or deep tissue surgery, the hand-washing nurse and the roving nurse must strictly check before the surgery and after the surgery before the suture, *** with the same sing to the number of instruments, large gauze pads, gauze, sewing needles, etc., inside the bag, and instantly by the roving nurse in the surgical nursing record sheet record and signature. Before and after the operation, the number of instruments and items in the bag in line with the check, before notifying the surgeon to close the surgical incision, to prevent the foreign body to stay in the body cavity.
4), surgical resection of biopsy specimens, should be hand-washing nurse and the operator to check, the establishment of a specimen registration system, a person responsible for pathology specimens sent for examination.
4, blood transfusion checking system based on the requirements of the Ministry of Health "Clinical Blood Transfusion Technical Specification", the development of blood drawing cross-equipped checking system, blood checking system, blood transfusion checking system.
1）Checking system of blood sampling and cross-matching
①Checking carefully the cross-matching list, the patient's blood type test list, the patient's bed number, name, gender, age, ward number and hospitalization number.
②, blood should be two nurses (a nurse on duty, should be assisted by the physician on duty), a blood, a check, check after the implementation of the correct.
3, blood (cross) after the test tube must be affixed to the bar code, and write the ward (No.), bed number, the patient's name, the handwriting must be clear and error-free, to facilitate the verification work.
④, blood specimens are drawn in full _ blood volume as required, and cannot be drawn from the vein of the limb that is being rehydrated.
5. If there is any doubt about the test order and the patient's identity when the blood is drawn, it should be rechecked with the doctor in charge and the senior nurse in charge on duty, and the correct test order and label should be filled out again instead of being modified directly on the wrong test order and wrong label.
2), blood collection checking system to the blood bank to collect blood, should carefully check the blood bag on the name, gender, bed number, blood bag number, blood type, the number of transfusions, the expiration date of the blood, as well as the appearance of the preserved blood, must be accurate; the blood bag must be placed in the sterile towel lined with a therapeutic tray or clean containers to be retrieved.
3）Transfusion checking system ①, pre-transfusion patient checking: two medical personnel shall check the patient's bed number, name, hospitalization number, blood type, blood volume on the cross-matched blood report form, and check the blood donor's name, number, blood type and the patient's cross-compatibility test result. Check whether the name, number and blood type on the label of the blood bag match with those on the crossmatch report form, and if they do, proceed to the next step of the examination.
②, pre-transfusion check: check the bag of blood collection date, the blood bag with or without extravasation, the appearance of blood quality, to confirm that there is no hemolysis, clotting, no deterioration before use. Check whether the transfusion apparatus and needles used are within the validity period. Do not oscillate the blood after taking it out of the blood bank, do not warm it up, do not put it into the refrigerator for freezing, and do not leave it at room temperature for too long.
3. When transfusing blood, two health care workers (carrying medical records and cross-matched blood sheets)**** go to the patient's bedside to check the bed number, ask the patient's name, check the bedside card, and ask about the blood type in order to confirm the blood recipient.
4. Before and after blood transfusion, flush the transfusion vessels with intravenous saline. When transfusing blood from different blood suppliers continuously, flush the transfusion apparatus with intravenous saline after the previous bag of blood has been transfused and then continue to transfuse another bag of blood. During the transfusion period, the patient is closely monitored for transfusion reactions.
5. After completing the blood transfusion operation, check the medical prescription again, patient's bed number, name, blood type, blood type of the matching sheet, blood type of the blood bag label, blood number, name of the donor, date of blood collection, and then sign after confirming that there is no error. Post the record sheet (crossmatch report form) in the medical record and return the blood bag to the Transfusion Unit (Blood Bank) for storage for at least one day.
5. Diet checking system
1) After daily checking of medical orders, check the patients' bedside dietary signs based on the dietary list, check the name of the bed number, the type of diet, and publicize the clinical significance of therapeutic diet to the patients.
2) Before distributing the diet, check whether the dietary list is consistent with the type of diet.
3) Check again at the patient's bedside before starting the meal.
4), fasting patients, should be in the diet and the end of the bed with a conspicuous sign, and tell the patient or family members of the original time limit of fasting.
5), due to the condition of the patient's food restrictions, their families to send food, need to be checked by medical staff before eating
(B) shift handover system
1, the duty officer should be strictly in accordance with the nursing management system, to obey the head nurse arrangements, adhere to the workplace, perform their duties to ensure that the treatment and care work carried out accurately and in a timely manner.
2, before the shift, the nurse in charge should check the implementation of medical advice and critical care records, focusing on the inspection of critical and new patients, in the shift arrangements for the nursing work.
3, each shift must be on time to hand over, the receiver 15min ahead of time to the department, read the nursing records, the handover to do seven not to (the number of patients is not allowed, the condition is not clear, the bed is not clean, the patient's skin is not clean, the pipeline does not work, the treatment has not been completed, as well as the number of items do not match the handover).
4, the duty must be completed before the shift shift records and the work of the shift, deal with the goods, for those who take over to do a good job with the goods ready, such as disinfectant dressings, test tubes, specimen bottles, syringes, standing instruments, clothing and so on, in order to facilitate the work of those who take over. In the event of special circumstances, you must give a detailed explanation, and the successor **** with a good job before leaving.
5, the morning shift, by the night shift nurse report condition, all personnel should seriously listen to the night shift deduction by the head nurse led by the day and night shift nurses *** with the tour of the ward, bedside handover of the condition and the management of the ward.
6, the contents of the shift include:
①Total number of patients, discharged from the hospital, transfer, transfer, delivery, surgery, the number of deaths, as well as new people in the hospital, the patient, the patient, the rescue patients, before and after major surgery or a special examination and treatment, behavioral anomalies, suicidal tendencies of the disease / human changes and psychological status.
②The implementation of medical advice, critical care records, a variety of test specimen collection and a variety of disposal completed, unfinished work, should be clearly explained to the successor.
3 check coma, paralysis and other critical patients with or without pressure ulcers, as well as the completion of basic care, a variety of catheters and patency.
④The quantity and technical status of valuable, poisonous, anesthetic and psychotropic drugs and rescue medicines, instruments and apparatus with full names.
7, the shift handover *** with the tour to check whether the ward to meet the clean, neat, quiet requirements and the work of the actual situation.
8, the rest of the shift in addition to the detailed handover, should *** with the tour of the ward, bedside handover.
9, shift handover if you find the condition, treatment, equipment, goods account is not clear, you should immediately inquire. If problems are found during the shift, the person who takes over the shift should be responsible for it; if an error occurs after the shift is taken over due to unclear explanation, the person who takes over the shift should be responsible for the error or loss of goods.
10, shift report (nursing records) should be written in neat, clear handwriting, focused. Nursing records are objective, true, timely, accurate, comprehensive, concise, coherent, and use medical terminology. When the advanced nurse or practical nurse writes the nursing record, the teaching nurse is responsible for revising and signing.