According to the spirit and regulations of the relevant documents of the higher authorities, our hospital immediately carried out a major medical quality inspection and made the following conclusions: First, strictly control the medical quality to ensure medical safety.
1, carry out clinical work in strict accordance with the process and diagnosis and treatment guidelines to ensure medical quality and safety.
2. Strictly implement the doctor's rounds system, and make detailed rounds on the illness records: records of illness analysis, medical treatment and the next diagnosis and treatment plan.
3, strictly implement the management system of medical practitioners.
4, strictly implement the doctor on duty system.
5. Do a good job of "night rounds". "Night rounds" include the follow-up of newly admitted patients and critically ill patients, the results after medical treatment during the day, the analysis and processing of test results, the results of special examinations, the communication of informed consent forms (especially for patients about to undergo surgery or invasive examinations), the arrangement of patients discharged tomorrow, and the handling of patients for consultation. And hand over the work with the doctor on duty.
6, do a good job of succession. The morning shift and afternoon shift before going to work are particularly important, and critically ill patients must be handed over at the bedside. The doctor on duty every day must refer to the checklist of undergraduate patients in detail after taking over, and handle and review the abnormal results.
7, a consultation system.
8, the department set up a doctor who is responsible for the quality inspection of medical records, spot-check medical records and do a good job of quality control, and correct mistakes in time.
9, according to the feedback information of patient rounds, put forward opinions, found the problem, timely rectification, to avoid making the same mistake.
10, led by the department director every month, learning business, updating new knowledge and progress in diagnosis and treatment.
1 1. Conduct irregular and irregular quality inspection on the department, find problems, rectify within a time limit and help implement them.
12, set up a consultation and discussion system for difficult cases, aiming at improving the overall academic level of all subjects while solving the diagnosis and treatment of difficult cases, and at the same time training doctors and improving their clinical professional ability and level.
Second, implement various systems, strengthen communication between doctors and patients, and enhance understanding between doctors and patients.
1, communication is a very important link.
(1) Do a good job of communication when entering the hospital: let the patients and their families know about the patient's current condition, ask the doctor to explain the condition in detail for critically ill patients, and sign a notice of serious illness (danger) if necessary. Let patients and their families know the names of doctors and nurses and the time of communication.
(2) Communication during hospitalization: illness change, examination results and treatment plan; Especially when there are major changes in diagnosis and treatment, it is necessary to communicate in time. For patients who can't come to the hospital in time to know their condition during the day, they must give their condition to the doctor on duty so that their families and doctors on duty can know their condition.
(3) Communication before discharge: the diagnosis and treatment results of the disease, the time of outpatient follow-up and the possible side effects of drugs, the treatment methods when the condition may change, and the examination items that need to be reviewed.
(4) Communication with outpatients: diagnosis and treatment of diseases, effects and side effects of drugs, follow-up time, etc.
(5) Communication between doctors and nurses: timely implementation of medical behaviors, timely inspection, and timely handling of patient's condition changes, with medical hidden dangers or disputes.
2. Conscientiously implement the signed informed consent.
For related treatment, the person in charge must communicate face to face with the family members and patients, explain the necessity, indications, possible risks and complications, medical expenses and time of medical observation or treatment to the family members of patients, and sign an informed consent form.
3. For patients with potential safety hazards, such as critically ill patients, patients with large fluctuations, patients with mental disorders, patients who do not cooperate with medical operations, patients who go out casually, etc., we must do a good job in explaining and obtain the cooperation and understanding of patients' families. Full-time escort personnel should be set up when necessary, and the handover work should be done well.
Self-inspection report on drug quality management in the second hospital
20xx Annual Drug Quality Management Self-inspection Report According to the Notice on Carrying out Special Remediation of Drug Safety in Medical Institutions issued by the leadership of the Food and Drug Administration in 20xx, our hospital conducted self-inspection according to the training contents of the Food and Drug Administration. The results of self-inspection are summarized as follows: 1. Leaders attach importance to it and the management organization is sound.
Our hospital has established the Hospital Pharmacy Management and Pharmacotherapy Committee, which is responsible for supervising and guiding the scientific management and rational drug use of this institution. The pharmacy department has set up a drug quality administrator, who is responsible for drug quality management, defined the functions of each post, and established and improved the system of drug quality management in all aspects.
Second, the management of drugs
1.20xx In July, our hospital has purchased drugs through the online centralized procurement platform of XXX medical institutions. The drug procurement catalogue is determined according to the national essential drugs catalogue, the urban medical insurance catalogue, the XXX cooperative medical care essential drugs catalogue and the actual clinical use, and approved by the hospital pharmaceutical affairs management and pharmacotherapy Committee. The pharmacy department makes online purchases according to the catalogue.
2. Establish supplier files and strictly review the qualifications of suppliers and sales personnel. Ensure that qualified drugs are purchased from legally qualified enterprises.
3. According to the Drug Administration Law and relevant drug laws and regulations, combined with the actual situation of our hospital, formulate relevant drug quality management systems, including drug procurement, acceptance, maintenance system, prescription deployment and prescription management system, recent drug management system, special drug management system, adverse drug reaction reporting system, etc.
4. The purchased anesthesia is managed according to the regulations, stored in the counter, equipped with anti-theft facilities, and managed by two people and two locks. The special account record is consistent with the account.
5, the implementation of drug storage management, the validity of less than 6 months of drug listing warning. Report to all user departments for promotion.
6. Pharmacy and drug warehouse regularly check and maintain drugs in the morning and afternoon, detect the temperature and humidity and make records, and take timely control measures when it exceeds the specified range.
Third, the management of medical devices
1. Our hospital purchases medical devices from legitimate medical device suppliers, establishes supplier files, and strictly examines the qualifications of suppliers and sales personnel. Ensure that qualified medical devices are purchased from legally qualified enterprises.
2. Establish and complete the purchase and acceptance records of medical devices.
3, according to the relevant requirements of drug management of medical devices in the library, according to the requirements for maintenance and storage. Every morning and afternoon, the medical devices in the warehouse are inspected and maintained regularly, and the temperature and humidity are detected and recorded. If it exceeds the specified range, control measures should be taken in time.
Fourth, the management of pharmacies.
1. Place drugs according to the requirements of standardized construction of pharmacies, with obvious regional positioning signs, and store internal and external drugs separately, and store smelly and dangerous goods counters separately.
2. According to the requirements, the pharmacy will maintain the displayed drugs every month, keep a maintenance record account, regularly monitor the temperature and humidity every morning and afternoon, and make records. Beyond the prescribed scope, take timely control measures.
3, by the pharmaceutical professional and technical personnel to review the prescription, deployment, dispensing and safe medication guidance.
4. Strictly implement the system of "four checks and ten pairs" when dispensing prescriptions to ensure the accuracy of drug distribution. 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. Audit and deployment personnel should sign the prescription.
5, strictly implement the relevant provisions of the prescription management, prescription effective from the date of issuance, special circumstances need to be indicated by the director of the validity period, by the prescriber indicate the validity period, but the validity period shall not exceed 3 days, prescription drug dosage is generally not more than 7 days; Emergency prescription is generally not more than 3 days; Special drugs should be strictly regulated.
6. Save prescriptions in strict accordance with regulations: general prescriptions, emergency prescriptions and pediatric prescriptions 1 year.
7. Every year, people who have direct contact with drugs have to undergo health examination.
8, seriously implement the adverse drug reaction monitoring and reporting system, there are people who are responsible for information collection and reporting. The responsibility of drug quality and management is great. In the next step of management, we will take self-examination and self-correction as a new starting point and carry out the following work in a down-to-earth and effective manner:
(1) Strengthen the management of hospitals and departments, improve drug quality management, and ensure drug safety and medical safety.
(2) Establish a long-term mechanism for scientific management of hospital drug quality, and strictly implement the laws and regulations on drug quality management.
(3) Strengthen the management and use of high-risk drugs and antibacterial drugs.
(4) Strengthen the induction training for new employees and the continuing education and training for old employees.
(5) Strengthen the inspection, assessment and review of the implementation of various management systems.
Article 3 Self-inspection report on drug quality management in hospitals
In recent years, with the strong supervision and support of higher authorities, our hospital, together with other brother hospitals, has devoted itself to the development of rural Chinese medicine, making rural Chinese medicine the top priority of our annual work. According to the construction standards and assessment scale of township hospitals with characteristics of traditional Chinese medicine in xx province and the spirit of relevant documents and instructions of the Health Bureau, our hospital strives to strengthen the organization and leadership of rural Chinese medicine work and the construction of rural Chinese medicine service network, and further improve the basic conditions of Chinese medicine in our hospital and village clinics. And carry out Chinese medicine knowledge and appropriate technical training for Chinese medicine personnel and rural doctors in a planned and step-by-step manner to improve the ability and quality of Chinese medicine services in rural medical institutions. First, we attach great importance to raising awareness.
After receiving the relevant documents and notices, our hospital attached great importance to it. The hospital has set up a leading group for Chinese medicine, which consists of six people, including Jing Xijun, vice president of the hospital, Zong, Gao Qinglin and Du Haijun, director of the pharmacy department, and has held many meetings of the leading group, asking all departments of the hospital and village clinics to pay more attention to and implement measures, recognizing that the establishment of advanced units for rural Chinese medicine work is a good opportunity to promote the development of rural Chinese medicine, better popularize Chinese medicine culture and benefit the people. Everyone should raise awareness, unify their thinking, respond positively, and conscientiously do a good job in the creation work in accordance with the requirements of leaders at all levels in the region.
Second, make plans and actively implement them
According to the Construction Standards and Assessment Scoring Form of Township Health Centers with Chinese Medicine Characteristics in xx Province, the Development Plan for Building National Advanced Areas of Rural Chinese Medicine Work in xx District and the Detailed Rules for Inspection and Assessment of National Advanced Units of Rural Chinese Medicine Work, the hospital has formulated the Implementation Plan of Rural Chinese Medicine Work in xx Central Health Center, which integrates all kinds of rural Chinese medicine work data and information since 20xx.
Third, the results of self-examination.
(a) to strengthen the organization and leadership and the construction of Chinese medicine service network.
Since the beginning of the work, the party and government leaders in our town have attached great importance to the rural Chinese medicine work, taken the initiative to assume the responsibilities and tasks of developing Chinese medicine work, set up a leading group for Chinese medicine work, set up an office, formulated an annual plan and specific implementation plan for Chinese medicine work, and organized their implementation. At the same time, our hospital has also established a leading group for establishing advanced units of Chinese medicine at the grass-roots level and a guiding group for rural doctors' Chinese medicine business. The leading group regularly holds special meetings to study and deploy Chinese medicine and solve practical problems.
(2) Improve institutional setup, facilities and equipment.
The department of traditional Chinese medicine was established, and a new museum of traditional Chinese medicine was built in our hospital on 20xx 10, which fully embodies the cultural characteristics of traditional Chinese medicine in decoration and forms a relatively independent comprehensive service area of traditional Chinese medicine, including consulting room of traditional Chinese medicine, treatment room of traditional Chinese medicine, traction room and acupuncture physiotherapy room. Set up a Chinese pharmacy, equipped with Chinese herbal medicine pieces cabinet (medicine barrel), medicine cabinet, dispensing table, medicine basket, standard sieve and decocting machine. At present, our hospital is equipped with 280 kinds of Chinese herbal pieces and 85 kinds of Chinese patent medicines. Can provide decocting service for patients. In order to better popularize the appropriate technology of traditional Chinese medicine and develop the cause of traditional Chinese medicine more widely, the Health Bureau has equipped our hospital with a number of basic facilities and diagnosis and treatment equipment suitable for the development of traditional Chinese medicine, including acupuncture treatment bed, massage treatment bed, TDP magic lamp, electroacupuncture therapeutic instrument, wax therapy instrument, cervical and lumbar traction bed, and purchased acupuncture equipment, cupping, scraping oil and scraping board.
(three) actively promote the appropriate technology, to carry out a wide range of Chinese medicine business.
According to the principle of "simplicity, experience and cheapness", TCM doctors in our hospital use 1 1 TCM appropriate techniques including acupuncture, moxibustion, massage, cupping, application, scraping, fumigation and washing, acupoint injection, wax therapy, bloodletting therapy and traction to carry out the diagnosis and treatment of various common diseases. Among them, the outpatient and emergency department of TCM accounts for 34% of the total outpatient and emergency department; The income of traditional Chinese medicine accounts for 35% of the total drug income, the income of traditional Chinese medicine accounts for 33% of the total business income, and the qualified rate of traditional Chinese medicine prescription writing is over 95%; Chinese medicine outpatient medical records have not been implemented.
In terms of drug management and use, our hospital strictly implements the national basic drug system, strictly manages the use of Chinese herbal pieces and proprietary Chinese medicines, and strictly implements the relevant standards and norms of Chinese medicine.
In the aspect of TCM physique appraisal service, health guidance is provided according to residents' different constitutions and recorded in residents' health records. However, due to insufficient publicity on the basic knowledge of traditional Chinese medicine, this work has almost stopped. At present, our hospital has actively taken corresponding measures.
In developing TCM rehabilitation services, our hospital can basically use traditional Chinese medicine rehabilitation methods combined with modern physical therapy methods to carry out rehabilitation treatment of neck, shoulder, back and leg pain, stroke sequelae and other diseases.
(four) to carry out health education and popularize the knowledge of Chinese medicine.
Health education is one of the basic public health service items determined by the state. Health education plays an important role in improving people's health literacy, advocating healthy lifestyle, and preventing and controlling infectious diseases and chronic diseases. In order to better implement health education, our hospital actively produces health education materials of traditional Chinese medicine, including written materials with traditional Chinese medicine as the main content, and sets up publicity columns to popularize education. Formulate the popularization plan of Chinese medicine knowledge, carry out public health consultation of Chinese medicine, and guide rural residents to understand the knowledge and methods of Chinese medicine health care.
(five) to strengthen business training and further study.
In order to meet the needs of the development of traditional Chinese medicine in my hometown, our hospital sent 1 TCM professionals to Dingxi Traditional Chinese Medicine Hospital to study acupuncture and physiotherapy. According to the requirements of the relevant documents from the higher authorities and the business needs of the hospital, our hospital organized senior doctors to conduct centralized business training and study for the newly recruited personnel in village clinics and Chinese medicine practitioners, and achieved certain results.
Iv. major problems and difficulties
Through this self-examination work, there are still many problems and difficulties in rural Chinese medicine work in our hospital.
(A) the lack of traditional Chinese medicine pieces, some traditional Chinese medicine inventory time is too long, poor quality.
(2) Do not write outpatient medical records, and there are fewer inpatients in Chinese medicine.
(3) In terms of developing appropriate technologies of TCM, due to limited conditions or immature technologies, technologies such as acupoint application and drug fumigation have not yet been developed. Although other technologies have been widely developed, their standardization still needs to be strengthened.
(4) Some measures have been taken for the overall decoration of TCM service area, but it still does not meet the requirements, and has not yet formed an antique, simple and natural atmosphere of TCM culture.
(5) The popularization of Chinese medicine knowledge and the intensity and depth of education need to be strengthened, and this work has not been deeply rooted in the hearts of the people. Coupled with the busy farming season, residents have no time to take care of it, which restricts the development of TCM physique appraisal service, TCM health education and TCM health care for special people.
Five, the next step of work ideas
First, actively strive for career funds to provide economic security for the work of traditional Chinese medicine; Second, continue to focus on the key work of rural Chinese medicine, strengthen supervision and implementation, actively coordinate the relations between all parties, gradually complete various indicators, and comprehensively promote the work progress; The third is to further standardize various technical operations, and to retrain, study and re-evaluate practitioners of TCM-related majors in order to improve the quality and level of TCM services.