1. Report on self-examination and self-correction of medical behavior (1)
First, medical quality management Our hospital pays close attention to service quality, strictly guards against medical errors, practices according to law, and practices medicine in a civilized way. The hospital has set up a leading group for medical quality management headed by Vice President Zhang, which regularly checks prescriptions and medical records, timely feeds back relevant responsible persons and supervises the medical quality of the hospital. The quality control of each single disease has reached the standards of the city and district.
Second, medical documents
Strictly abide by the requirements in the Basic Specification for Medical Record Writing, and write all medical documents objectively, truly, accurately, timely and completely for patients.
Third, rules and regulations
Our hospital has improved and implemented a series of rules and regulations, and improved various management systems, including thirteen core systems, new technology access system, pharmaceutical affairs management system, and public emergencies management system. For patients who see a doctor on the spot, they are required to show their medical certificates and ID cards when registering, and the hospitalized patients are required to submit copies of the two certificates during hospitalization, and carefully check them to prevent impersonation. Strictly grasp the admission criteria, follow the outpatient treatment, resolutely not be hospitalized, be admitted to the hospital in strict accordance with the criteria, do not arbitrarily reduce the hospitalization index, and do not delay the hospitalization day.
Our hospital strictly abides by the relevant medical insurance system, organizes the medical staff of the whole hospital to study the relevant medical insurance policies repeatedly, and carries out assessment work. The assessment results are linked to the distribution of personal interests.
Fourth, the basic drug system.
For the examination and treatment of inpatients, our hospital strictly follows the provisions of the Catalogue of Essential Drugs. Every doctor is required to strictly abide by professional ethics, and earnestly carry out reasonable examination, rational drug use, reasonable treatment and reasonable fees. If low-priced drugs can be used, there is no need for high-priced drugs, thus effectively reducing the burden of medical expenses for farmers. The inventory of drugs in the drug storehouse has reached more than 90% as stipulated in the catalogue. The dosage of prescription drugs is strictly controlled. In-patients should use drugs for no more than 3 days, and discharged patients should use drugs for no more than 7 days. It is strictly prohibited to prescribe drugs, show human feelings and abuse drugs, and the number of days of taking drugs out of the hospital shall not exceed the actual number of days of hospitalization. Check in strict accordance with the regulations, and resolutely put an end to the phenomenon of one-person medical insurance for the whole family.
Verb (abbreviation of verb) medical expense control
Our hospital charges in strict accordance with the charging standards jointly formulated by the departments of price, health and finance of provinces, cities and districts. Pay close attention to connotation construction, improve service quality, shorten the average hospitalization days of patients, and strictly control hospitalization expenses.
2. Report on self-examination and self-correction of medical behavior 2
In order to implement the quality inspection of drugs and medical devices in our hospital by the US Food and Drug Administration, ensure the safe and effective use of medical devices by the people, and standardize the use and management of drugs. The hospital set up a self-examination team headed by the dean. According to the Notice on Strengthening the Safety Management of Drugs and Medical Devices in Medical Institutions at All Levels, the Drug Administration Law, the Quality Management Standard for Drug Use and the Work Standard for Regulating Pharmacy, the self-inspection team has done a lot of detailed self-inspection, and now the self-inspection report is as follows:
Our hospital has legal qualifications such as practicing license of medical institutions. A drug quality management organization was established, which was composed of the director, the head of pharmaceutical machinery department, the head of pharmacy, the head of quality and the buyer, and the responsibilities of personnel and organizations at all levels were defined. At the same time, various quality management rules and regulations have been formulated as a guarantee and carefully organized and implemented. At the same time, the Pharmaceutical Affairs Management Committee of our hospital and the supervision and guidance group for clinical rational use of antibacterial drugs have been established and improved.
Our hospital has formulated a continuing education and training plan, focusing on the training of laws and regulations, such as the Drug Administration Law of People's Republic of China (PRC), the Regulations on the Administration of Pharmaceutical Affairs in Medical Institutions, the Regulations on the Supervision and Administration of Medical Devices, the Guiding Principles for Clinical Application of Antibacterials, the Measures for the Administration of Clinical Application of Antibacterials, the Measures for the Administration of Prescriptions, the special rectification plan for clinical application of antibiotics in Inner Mongolia Autonomous Region in 20xx, and the basic principles of ethnic medicine and medical care.
Regarding the normative documents issued by He Qi Health Bureau on strengthening the supervision and management of drugs and medical devices and improving the quality of personnel, we will further standardize all aspects of drugs and medical devices from procurement, acceptance, storage and use, and strictly follow the regulations. Every year, people who are in direct contact with drugs are examined for health, and health records are established to ensure the safety and effectiveness of drug use.
Second, the procurement and acceptance:
Purchased drugs in strict accordance with the centralized drug procurement system formulated by the superior health bureau. Purchasing drugs from enterprises with pharmaceutical production and business qualifications; The acceptance of drugs in storage shall be carried out in strict accordance with the standard operating procedures, and the quality of drugs purchased and returned after sale shall be accepted batch by batch in strict accordance with the statutory quality standards and contract quality terms.
Three, the implementation of standardized pharmacy management system:
In strict accordance with the standard of standardized pharmacy, the Meng Xi pharmacy and drug storehouse in the whole hospital are managed.
Four, drug storage and maintenance:
The warehouse is divided into drug warehouse and medical device warehouse, and each warehouse is divided into qualified area, pending inspection area and unqualified area. Each area is managed according to the regulations, that is, the qualified area is green, the returned area to be inspected is yellow, and the unqualified area is red. After the acceptance, the special drug warehouse should be stored in strict accordance with the drug storage and maintenance system, and stored in the corresponding reservoir area according to the drug storage conditions and requirements. Drugs should be piled up in a centralized way according to the batch number and expiration date, or stacked separately according to the order of batch number and expiration date, and drugs near the expiration date should fill in the expiration date table every month.
Five, the deployment of drugs:
Pharmacists must prepare drugs with prescriptions issued by registered medical practitioners, and drugs may not be prepared without prescriptions issued by doctors. Drug preparation should be carried out in strict accordance with the requirements of four checks and ten pairs, and distribution should follow the principles of "production first, distribution first", "distribution first in the near future" and distribution according to batch number.
Six, adverse reaction monitoring:
Establish an adverse drug reaction monitoring and management team, designate full-time or part-time personnel to be responsible for reporting and monitoring adverse drug reactions, establish and save adverse drug reaction monitoring files, actively collect adverse drug reactions, and report them through the national adverse drug reaction monitoring information network. The contents of the report shall be true, complete and accurate.
Seven, special drugs:
Special management drugs have safe storage measures that meet the requirements, and five special management methods are implemented, such as double locks for two people and matching accounts and goods. The purchased special drugs shall be accepted upon arrival, unpacked by two persons, counted according to the minimum package, and special acceptance records shall be kept. The returned, expired and unqualified specially managed drugs and wastes recovered according to regulations shall be destroyed under the supervision of the health department, and the destruction records shall meet the requirements.
Eight, problems found in the inspection:
Through the self-inspection team, all aspects of hospital drug use and quality management were self-inspected, including personnel organization, management system, hardware facilities, management records, etc., which basically met the requirements of drug use quality management norms. However, we also found some shortcomings, such as poor sanitary conditions, irregular drug placement, irregular classification, unclear zoning, and insufficient written records in some places involving medical equipment. Ordered the relevant personnel of all departments to seriously rectify according to the system and implement it to people.
Nine, rectification:
On the basis of self-examination and mutual inspection, our hospital respectively rectified the following problems:
1. Formulated the system and labels of confusing drugs, and attached them next to the classified confusing drugs.
2. Formulated the on-the-job education and training system and training plan focusing on ethnic medicine.
3. The system of medical device incoming inspection record is established.
4. The monitoring system of medical device adverse events was established.
5. Strengthen the maintenance of large medical equipment. Supplementary medical device inspection, maintenance and related records will be implemented for a long time.
6. Strengthen the monitoring of adverse reactions and medical device adverse events.
In actual work and implementation, there may be some subtle problems that are easily overlooked. I hope the superior leaders will put forward valuable opinions on our work. In the future work, we will make persistent efforts to do a better job in pharmaceutical affairs in our hospital and ensure the safety of people's medication.
3. Report on self-examination and self-correction of medical behavior (3)
A series of medical accidents occurred in xxxx, and the alarm of medical quality and safety sounded again. In xx county and xx county, two medical accidents occurred in succession. The first is "right leg fracture, left leg operation", and the second is "left hernia, right side operation". The doctors in charge of these two patients were treated because of their lack of responsibility, and the "xxx incident" occurred in xxx hospital. When the child's condition deteriorated, the doctor was found playing online games. Afterwards, it was determined that the relevant medical staff had serious dereliction of duty in this incident. At the beginning of xx, CCTV reported that xXX, a professor of XX medicine, died in the First Hospital of Peking University, pointing out that many interns in the hospital had irregularities in working independently during the medical treatment. The above incident once again sounded the alarm that medical accidents are fiercer than tigers. We should not forget the past, but learn from the future. These events deserve our reference and deep thought. We are medical workers, not angels in white. In the future, we should have a heart of love and dedication, and we should have a consistent and down-to-earth work. Now start from now, start from yourself. I also realize that we should pay attention to the quality of medical care. As a resident, I summarize my situation as follows:
(1) Patients should be examined within 30 minutes of admission and given initial treatment.
(2) Acute, dangerous and severe patients should be treated immediately and reported to the superior doctor.
(3) Complete the medical record writing within the specified time (within 24 hours for ordinary patients and 6 hours for critically ill patients; The first course record is completed on duty, and emergency patients are completed before operation).
(4) The medical records shall be written in a complete and standardized way, and there shall be no missing items. I should strengthen the study of medical record writing. Correct the shortcomings. The handwriting is not good, you need to practice.
(5) Complete blood, urine and stool examination within 24 hours, and complete liver, renal function and other required special examinations as soon as possible according to the condition.
(6) Make a preliminary diagnosis and treatment plan according to the routine of specialist diagnosis and treatment.
(7) For responsible patients, make rounds at least once a day in the morning and afternoon.
(8) Complete the course record according to the specified time and requirements.
(9) The patient's condition changes should be reported to the superior doctor in time.
(10) In the process of diagnosis and treatment, disinfection and isolation regulations should be observed, and strict aseptic operation should be carried out to prevent hospital infection cases. If there are any hospital infection cases, fill in the form and report it in time.
(1 1) When the patient is discharged from the hospital, it must be approved by the superior doctor, and the discharge doctor's advice should be indicated to explain the matters needing attention.
(12) Strictly follow the routine diagnosis and treatment, and do not violate the hygiene regulations. We should strengthen the study of health law in the future.
(13) Strengthen communication between doctors and patients. Make your own contribution to the harmonious doctor-patient relationship.
Looking back on the past medical accidents, which one did not happen because of carelessness or failure to follow the routine operation of diagnosis and treatment? Therefore, in practical work, we should prevent small things from delaying, start from small things, deal with unsafe factors in time, and avoid seeking medical treatment. In fact, it is not difficult to achieve medical safety. The key is the sense of responsibility. As long as everyone pays more attention, as long as they have a serious and responsible attitude towards their work and do their duty in their posts, they will do their duty. No matter where you live, as long as you have a high sense of responsibility and a strong sense of mission, you will be able to avoid medical accidents.
4. Report on self-examination and self-correction of medical behaviors (IV)
According to the instructions and regulations of the US Food and Drug Administration, under the organization of the hospital leaders, a comprehensive inspection of the medical instruments and equipment in the hospital was carried out. The specific situation is now reported as follows: 1. Strengthen management, strengthen responsibility and enhance the sense of quality responsibility.
Equipped with medical device quality management personnel, with medical device-related professional knowledge, familiar with relevant laws and regulations, able to perform medical device quality management responsibilities, effectively undertake medical device quality management responsibilities in our hospital, guide, supervise and continuously improve the implementation of quality management system, collect laws and regulations and product quality information related to the use quality of medical devices, and implement dynamic management. And establish files, urge relevant departments and post personnel to implement medical device laws and regulations, review the legal qualifications of medical device suppliers and medical device products, be responsible for the acceptance, purchase and maintenance of medical devices, check the quality of medical devices, supervise and handle unqualified medical devices, organize the investigation and handling of medical device quality complaints and quality accidents, organize the monitoring and reporting of medical device adverse events, and establish a use quality management system covering the whole process of quality management.
II. Procurement, acceptance and storage of medical devices.
In order to ensure the quality and use safety of purchased medical devices and prevent unqualified medical devices from entering, our hospital has established the management system of purchasing, acceptance and storage of medical devices, the bidding and purchasing system of large-scale equipment and the file management system of medical devices. According to the provisions of the Measures for the Supervision and Management of the Use Quality of Medical Devices, our hospital has reorganized the purchasing and acceptance records and relevant files of medical devices. And log on to the website of the US Food and Drug Administration to verify the registration number of medical devices, and put an end to unlicensed purchase, fake certificate purchase, voucher purchase, and the purchase of imported medical devices that have no Chinese instructions, Chinese labels and Chinese labels, and have expired, so as to ensure the safe and legal use of medical devices.
Three, medical equipment warehouse storage conditions of self-examination.
In order to ensure the quality of medical devices stored in the warehouse, our hospital inspected the material warehouse, laboratory warehouse and warehouses of various departments, including whether the storage temperature, humidity and surrounding environment meet the storage conditions of medical devices in the warehouse. We also organize specialized personnel to do routine maintenance of medical equipment.
Four or three types of medical devices self-examination (focusing on implantable medical devices)
Implantable medical devices belong to high-risk medical devices. In order to ensure the safety and effectiveness of people's use of implantable devices, our hospital has specially formulated the procurement management system of implantable medical devices. Strict regulations have been made on the conditions of purchased medical devices and the qualifications of suppliers, and a series of qualifications submitted by implantable medical devices have been strictly reviewed and verified in accordance with relevant laws and regulations. Strengthen the information management of implantable medical devices, establish and improve the review system for procurement, warehousing, storage, use and scrapping of implantable medical devices, record product information in detail, and manage all information in patient medical records.
V. Detection and management of medical devices with suspected adverse reactions.
In order to strengthen the management of unqualified medical devices and prevent unqualified medical devices from entering the clinic, our hospital has specially formulated a medical device adverse event reporting system. In case of medical device adverse events, the location, time, adverse reactions or basic information of the adverse events should be quickly identified, recorded and reported to the medical device supervision and management department.
Six, medical equipment maintenance, maintenance and after-sales service of self-examination.
In order to make the medical equipment in a safe state and meet the technical requirements and standards, our hospital has formulated a medical equipment maintenance system, and made a medical equipment maintenance record according to regulations, recording the causes of equipment failures, accessories that need to be replaced and the state after maintenance. Our hospital also made the Inspection Record of First Aid and Life Support Medical Equipment for emergency medical equipment, requiring all departments to do a good job in the inspection of first aid equipment every day to ensure that the equipment is in a standby state.
Seven, the problems existing in the self-examination and the need for improvement.
After this period of self-examination and self-correction, the management of medical devices in our hospital is more standardized, but there are also some problems, such as: expired and unqualified medical devices in the warehouse cannot be destroyed in time, the classification and division of the warehouse are unreasonable, and the technicians engaged in medical device maintenance are not trained and assessed.
Eight, the future focus of medical devices in our hospital.
Effectively strengthen the safety of medical devices in hospitals, put an end to medical device safety incidents, and ensure the safety of patients using medical devices. In the future, we intend to:
1, further increase the publicity of medical device safety knowledge, implement relevant systems, and improve the awareness of hospital medical device safety responsibility.
2. Increase the frequency of daily inspection and supervision on the safety of medical devices in hospitals, timely investigate potential safety hazards of medical devices, firmly establish the awareness of "safety first", regularly train and assess technicians engaged in medical device maintenance, and improve service level.
3. Continue to actively cooperate with the higher authorities, consolidate the achievements made in hospital medical device safety work, create a good atmosphere for medical devices, and make greater contributions to building a harmonious society.
Chapter 5 Report on Self-examination and Self-correction of Medical Behavior
According to the requirements of "Measures for Drug Supervision and Management in Medical Institutions (Trial)", our hospital conducted a self-examination on drug quality management in our hospital for 20xx years, and now the results of the self-examination are reported as follows: 1. Leaders attach importance to it and the management organization is sound.
Hospital leaders attach great importance to the drug management in our hospital, and set up a hospital pharmacy management team and a drug treatment management team, which are responsible for supervising and guiding the drug procurement and examination and approval in our hospital, scientifically managing drugs and rationally using drugs, and the pharmacy department is specifically responsible for drug deployment and drug quality management, with clear post responsibilities and serious implementation.
Two, strengthen management, establish and improve the drug quality management system and pharmaceutical work system.
The hospital has established and improved a number of management systems, such as the classification management system of antibacterial drugs, the work system of pharmacy department, the prescription checking system of pharmacy, the management system of drug procurement, the work system of drug maintenance, and the responsibilities of pharmaceutical personnel. Through the construction of these systems, the hospital has improved the level of drug quality management and pharmaceutical work.
Three, strengthen business knowledge training and learning, improve the professional quality of personnel.
The hospital organizes employees to study business every month, learn pharmaceutical laws and regulations and professional knowledge of pharmacy, conduct relevant examinations and tests, and establish training files, which further improves the professional skills and professional knowledge of employees.
Fourth, strengthen drug management and attach importance to drug quality.
Strictly implement the management regulations of the superior management department on drug procurement. The drug procurement of our hospital is through the centralized procurement platform of drug equipment in Guangxi Zhuang Autonomous Region. The drug procurement catalogue is determined according to the national essential drugs catalogue, the urban medical insurance catalogue, the basic drugs catalogue of the new rural cooperative medical system and the actual clinical use. It is reviewed by the hospital pharmacy management team and drug treatment management team, and approved by the hospital leaders. According to the procurement catalogue, the Pharmacy Department purchased the winning drugs on the centralized procurement platform of pharmaceutical equipment in Guangxi Zhuang Autonomous Region. Establish supplier files, strictly review the qualifications of suppliers and sales personnel, and ensure that they have legal information.
Enterprises purchase qualified drugs. In strict accordance with the management regulations of the superior health management department and drug supervision department, our hospital purchased medical devices from Guangxi Jianyi Pharmaceutical Co., Ltd., a pharmaceutical business enterprise with pharmaceutical business qualifications. The business license, drug business license, GSP certification certificate, original power of attorney of sales staff and copy of ID card of drug business enterprise were filed, and a drug quality assurance contract was signed. According to the Drug Administration Law and relevant drug laws and regulations, combined with the actual situation of our hospital, the relevant drug quality management system has been formulated, including drug procurement, acceptance, maintenance system, prescription deployment and prescription management system, recent drug management system, special drug management system and adverse drug reaction reporting system. The purchased drugs with special management shall be managed according to regulations, specially stocked, equipped with anti-theft and monitoring facilities, and managed by two people and two locks. The special account record is consistent with the account. The purchased drugs have a legal tax receipt and a detailed list of suppliers. The list contains the generic name, manufacturer, batch number, specification, quantity, price and other contents of the drugs. The purchase acceptance system is implemented, and the purchased drugs are accepted by two people, and a true and complete drug acceptance record is established. Drug acceptance records include generic name, manufacturer, specification, dosage form, batch number, expiration date, supplier, quantity, price, purchase date, acceptance date, acceptance conclusion, etc. The procurement and acceptance records of drugs and devices should be complete, and the issuer and recipients should be responsible for double signing, and the records should be available for reference. Implement effective storage management of drugs, warn drugs with a validity period of less than 6 months in the management system, and report them to various departments for promotion. Pharmacies and drug storerooms conduct daily inspection and maintenance of drugs, report the loss of expired drugs and medical devices once a month, go through the formalities of reporting the loss and destruction, make a good record of destruction, and double sign by the destroyer and the seller, and report the loss of expired drugs throughout the year 1 1 batch. Pharmacies and drug warehouses are equipped with air-conditioning equipment with temperature and humidity control, and refrigerators for storing related drugs can be stored according to storage requirements.
Five, strengthen the management of pharmacy.
According to the requirements of standardized pharmacy construction, drugs should be placed with obvious regional positioning signs, internal and external drugs should be stored separately, and drugs that are prone to odor should be stored separately. Maintain the displayed drugs every day, monitor the temperature and humidity, and take control measures in time if it exceeds the specified range. Pharmaceutical technicians who are qualified according to law are responsible for the examination and deployment of prescriptions. Pharmaceutical professional and technical personnel review, allocate, distribute and guide the safe use of drugs. Strictly implement the system of "four checks and ten pairs" when dispensing prescriptions to ensure the accuracy of drugs issued. The prescription shall not be changed without authorization, and the prescription with doubt, incompatibility and overdose shall be refused to be prepared, and it can only be prepared after being corrected or re-signed by the prescriber when necessary. Both the examiner and the distributor signed the prescription. Strictly implement the relevant provisions of prescription management, the prescription is valid on the day of issuance, and the dosage of prescription drugs generally does not exceed 7 days; Emergency prescription is generally not more than 3 days; Special prescriptions should be strictly used for special drugs, and drug prescriptions should be kept for 2 years. Check people who have direct contact with drugs every year and establish health records. Workers who have direct contact with drugs are not suffering from infectious diseases or other diseases that may contaminate drugs, and are in good health.
Six, seriously implement the adverse drug reaction monitoring and reporting system.
In 20xx, our hospital reported 8 cases of adverse drug reactions, with adverse drug reactions 1 case and 50 cases of drug abuse to the drug supervision department.