Medical nursing defects refer to the routine behavior of medical personnel who violate medical and health management laws, administrative regulations, departmental rules and diagnosis and treatment nursing standards during medical activities. The reason may be medical Staff negligence may also be caused by patients, such as medical staff asking about medical history, patients deliberately concealing information, etc.

According to the degree of its impact on the patient, it can be divided into three degrees: mild, moderate and severe. Severe defect: seriously affects the efficacy or causes damage to important tissues and organs leading to dysfunction; or even causes serious adverse consequences such as disability and death. Moderate defect: affects curative effect, prolonging the course of treatment, causing recoverable damage to tissues and organs; or violating operating procedures, increasing patient pain and medical expenses, but without serious consequences. Mild defects: no impact on the patient or slight impact on the patient without adverse consequences . [1] Definition standard of medical nursing defects 1. Severe defects in medical record writing (1) Important omissions in chief complaint, history of current illness, and physical examination that cause diagnostic errors or affect treatment and rescue; (2) 24 hours for critically ill patients and 2 days for seriously ill patients There is no ward round by a superior physician, and no record of the course of the disease; (3) The death medical record has no records of death rescue, death discussion, etc.; (4) There is a lack of one of the first page of the medical record, inpatient medical records, discharge records, and disease course records; (5) There is no surgery for surgical patients. Signature records of pre-operative conversations, anesthesia records, surgical records, pre-operative and intra-operative care records, postoperative disease course records, and postoperative medical instructions. (6) Disability surgery, the first major surgery, and operations that do not have the signed consent of the patient’s family. Report to hospital leaders for approval. Moderate deficiencies (1) Past medical history, personal history, family history, and menstrual and childbearing history are missing; (2) No superior physician’s ward rounds opinion within three days of hospitalization or before surgery; (3) Hospitalization for 30 days There is no stage summary for the above; (4) There is no continuous disease course record for newly admitted patients and three days after surgery; (5) There is no diagnostic basis and diagnosis and treatment plan in the first disease course record; (6) There is no record of specialist status in the medical records of specialist patients; (7) Transfers to departments There are no transfer and admission records for patients; (8) Consultation sheets and various examination sheets are missing; (9) Shift handover records, superior physician’s ward rounds records and special treatment records are missing; (10) Critically ill patients are not discharged in time Those who are critically ill or have prematurely discontinued medical advice for critical illness. Mild defects (1) Incomplete completion of the home page, lintel and related forms; (2) The entire medical record does not have the signature of the superior physician; (3) There is no record of the course of the disease for more than three consecutive days (one week for chronic diseases) ; (4) Improper medical terminology or obvious text errors; (5) The arrangement of medical records or the pasting of checklists are not standardized. 2. Severe deficiencies in diagnosis (1) Errors or omissions in the diagnosis of major diseases, resulting in delayed treatment; (2) Difficulties , those who delay diagnosis and treatment in emergency or severe cases without consulting superior doctors or consultation; (3) those who damage important organs due to errors in the implementation of diagnostic measures; (4) those who rely on medical technology department inspection reports, resulting in incorrect diagnosis; (5) Delay in diagnosis due to failure to implement key inspection measures in a timely manner. Moderate deficiencies (1) Delay in diagnosis due to lack of conventional drugs or equipment failure; (2) Undiagnosed non-complex diseases for more than a week and failure to report according to diagnostic specifications; (3) The main diagnosis is established, and the diagnosis of complications is omitted, which affects the treatment; (4) The failure to implement diagnostic measures causes pain to the customer; (5) The diagnosis of the main disease is insufficient, resulting in inaccurate diagnosis. Mild defects (1) Difficult cases are not consulted in time , but did not affect the treatment; (2) The omission of secondary diagnosis or comorbidity did not affect the treatment; (3) Excessive use of unnecessary auxiliary examinations; 3. Treatment defects and serious defects: (1) Treatment principles and key points Wrong treatment measures; (2) Mishandling errors or improper use of medication causing severe pain or damage to the patient; (3) Severely ill patients being diagnosed clearly but not taking timely treatment measures, which increases the patient's suffering. (4) The patient's condition worsens during hospitalization and the doctor fails to do so. Timely discovery may lead to missed rescue opportunities and adverse consequences. Moderate defects (1) Improper medication or mishandling affects the efficacy, but does not cause damage; (2) Non-severe patients do not take timely treatment measures after a clear diagnosis; (3) Due to Insufficient preparation of conventional medicines or equipment results in prolonged treatment. Mild defects (1) Unreasonable use of medication leading to increased side effects;

(2) Improper auxiliary treatment without affecting the efficacy; (3) Abuse of unnecessary drugs or treatment methods; (4) Treatment measures are correct, but not approved according to standardized procedures. 4. Rescue defects and serious defects (1) Failure to rescue in time results in Delay in the rescue opportunity; (2) Misjudgment of the condition or failure to follow routine rescue operations resulting in errors; (3) Insufficient cooperation between departments during a multi-disciplinary rescue that affects the rescue effect; (4) Barriers in rescue drugs, equipment, and energy that affect the rescue Effect; (5) Improper operation during the rescue process causing damage to important organs; Moderate defects (1) Untimely rescue or ineffective measures; (2) Poor operation of equipment affecting rescue; (3) Ineffective cooperation between relevant departments during rescue; ( 4) Tissue damage caused by improper rescue operation. Mild defects (1) No guidance from superior doctors for rescue cases; (2) Rescue records and medical orders are not standardized and incomplete; (3) Rescue drugs and equipment are not properly prepared, but they do not directly affect the rescue effect. . 5. Severe surgical defects (1) Wrong choice of surgical method, site, and time leading to failure of the operation; (2) Improper surgical operation that damages important organs and affects the patient's physiological function; (3) Violation of operating procedures directly or indirectly causes massive bleeding. Shock; (4) Improper surgical operation or insufficient preoperative preparation, resulting in failure to achieve the purpose of surgery; (5) Non-therapeutic foreign bodies left in the body after surgery; (6) Failure to promptly report to superior doctors or consult for discussion when encountering complex situations during surgery and not properly handled; (7) Unexpected conditions occur during the operation, and the surgical method needs to be changed without informing and signing the formalities with the patient and his family, resulting in disputes after the operation. Moderate defects (1) Caused by rough surgery Excessive tissue damage, but no sequelae; (2) Improper operation leads to excessive blood loss, but does not cause hemorrhagic shock; (3) Improper operation leads to infection, hematoma, fistula, sinus formation and affects healing; (4) Violation of surgical hierarchical management Skip-level surgery; (5) The preoperative waiting time for elective surgery exceeds 5 working days without justifiable reasons. Mild defects (1) Foreign matter left in the incision affects healing; (2) Purulent lesions require poor incision and drainage. Expansion of drainage again or delayed healing; (3) Improper use of equipment causing patient injury; (4) Improper wound treatment after surgery affecting the incision healing as scheduled. 6. Severe deficiencies in nosocomial infection control (1) Occurred during hospitalization (not in the latent period) Statutory nosocomial infectious diseases infections and food poisoning; (2); (3) More than three infections of the same bacterial species in a short period of time due to improper disinfection. (4) Serious infectious diseases such as AIDS, hepatitis B, and hepatitis C caused by blood transfusions and infusions . Moderate deficiencies (1) Patients with notifiable infectious diseases have not been isolated and disinfected, but have not yet been cross-infected; (2) The number of cases of delayed healing due to infection in sterile wounds exceeds 0.5; (3) Improper medication causing secondary infection; (4) ) Blood-borne infection caused by blood transfusion. Mild defects (1) Instruments, dressings, and air disinfection are not up to standard, but infection has not yet been caused; (2) Infections occurred during hospitalization. (3) Contamination in laboratory departments, operating rooms, etc. Materials and sewage discharge do not meet the standards. 7. Serious defects in nursing: (1) Nursing monitoring errors and lax inspections lead to incorrect diagnosis and treatment, leading to adverse consequences; (2) Leaving work without authorization and delaying diagnosis, treatment and care, causing serious consequences; (3) Violation of aseptic technique, causing severe infection in patients; (4) Leakage of infusion (intravenous injection) causing tissue necrosis of more than 3x3cm; (5) Improper care leading to adverse consequences such as falling from the bed, suffocation, and fainting; ( 6) Delay in diagnosis, treatment, and nursing work due to careless shift handover, resulting in adverse consequences; Moderate defects: (1) Improper care caused bedsores, burns, frostbite, and poor drainage of body cavities; (2) Failure to make preoperative preparations on time and Delay in surgery, examination, and treatment time; (3) Various records have

Omissions or inaccuracies that affect diagnosis and treatment; (4) Loss of examination specimens that affect diagnosis and treatment. Mild defects: (1) Illegal operations that increase customer pain; (2) Various records are inaccurate, but do not affect diagnosis and treatment ; (3) Specimen retention or preoperative preparation is not timely, which has not affected the diagnosis and treatment; (4) Aseptic technique is unskilled, causing mild infection of the patient; (5) Critically ill patients have no care plan. 8. Severe defects in anesthesia (1) When an anesthesiologist is rescuing a client in a clinical setting, he or she forgets important equipment and the drugs affect the rescuer. (2) The anesthesiologist neglects his duty during the operation and causes respiratory and circulatory arrest, but the client recovers successfully after resuscitation. (3) Anesthetist suffers from anesthesia Pneumothorax is caused by improper puncture operation. (4) The anesthesiologist is irresponsible and causes anaerobic supply or carbon dioxide retention. (5) The anesthesiology department staff on duty stops the operation without reason, delays or shirks the operation, or leaves his or her duties without authorization, which affects the timely operation. . Moderate defects (1) Low spinal anesthesia was not performed according to routine operations, causing the level to be too high, causing respiratory depression, but no adverse consequences occurred after treatment. (2) Epidural anesthesia was not performed according to routine operations, resulting in puncture The dura mater or anesthesia catheter was forgotten in the body and brought back to the ward. (3) Because the anesthesia intubation was not performed according to routine, the patient's teeth became loose, fell out, and the throat was seriously damaged; Mild defects (1) Incomplete anesthesia seriously affected the operation (2) After the emergency surgery notice was delivered, the anesthesiologist failed to prepare for anesthesia within 30 minutes without special reasons. 9. Severe defects in the operating room (1) Misuse of unsterilized items in the operating room due to lax handover. (2) Falling from the car or bed before picking up customers in the operating room or before or after surgery. Moderate defects (1) Failure to carefully check and inventory dressings and instruments before closing the body cavity, resulting in extending the operation time by more than 30 minutes. (2) Operating room The main surgical instruments and medicines are not fully prepared, which affects the progress of the operation. Mild defects (1) The patient's skin is bruised or blistered due to fixed position or improper placement and incomplete protection. (2) Due to a weak sense of responsibility, Those who caused mild burns with hot water bottles or electrodes. 10. Severe deficiencies in the blood transfusion department (blood bank) (1) A report was issued for the wrong blood cross test; (2) The wrong blood was sent and entered to the customer, but it was discovered and dealt with in time. Moderate Defects (1) Wrong blood was given but not transfused into the customer's body; (2) After receiving the blood transfusion request form for critically ill, rescue patients; No blood was supplied for no reason within 30 minutes, affecting the rescuers; (3) Blood loss due to lack of responsibility Expired and scrapped or the packaging is damaged, resulting in a waste of more than 200 ml of blood. Mild defects (1) Loss of blood specimens requiring redrawing of blood; (2) Blood wastage of less than 100 ml due to damaged packaging; (3) Blood bottles ( The label on the bag is incorrectly filled in (name, blood type) or mislabeled, and has been issued but not used.