(a), doctor's advice check:
1, doctors should check the patient's name, gender, bed number, hospitalization number (outpatient number) and other information when issuing medical orders, prescriptions or making diagnosis and treatment.
2. When executing the doctor's advice, the nurse on duty must carefully read the contents of the doctor's advice, confirm the problematic doctor's advice, and print all kinds of execution cards after being correct.
3, dealing with the doctor's advice, it should be BANCHA to go to class.
4, when dealing with the doctor's advice and inspection, should sign the full name. The executor of temporary medical orders shall record the execution time.
5, all orders must be checked before execution, special orders must be checked by a second person before execution.
6. When rescuing a patient, the physician gives a verbal order, and the executor must repeat it and confirm it before executing it, and keep the used empty ampoule. After the rescue, the doctor should fill in the doctor's order and sign it in time. Ampoules should be kept until the end of rescue, and can only be discarded after being verified by two people.
(2), medication, injection and disposal inspection:
1. Before taking medicine, injection and disposal, the system of "three inspections and nine pairs" must be strictly implemented. Three examinations: preoperative examination, intraoperative examination and postoperative examination; Nine pairs: bed number, name, drug name, dosage, concentration, time, usage, expiration date and allergic history.
2. Check the quality of drugs before preparation, and pay attention to the deterioration of aqueous solution and tablets; Whether there are cracks in ampoules and injections, pay attention to the validity period and batch number, and whether the solution has precipitation, turbidity, floc and so on. (Observe after vibration). If the quality does not meet the requirements, there is doubt or the identification is unclear, it shall not be used.
3, after placing medicine must be checked by a second person rear can perform.
4, oral drugs should assist patients after taking, can leave.
5. Allergic drugs, such as penicillin and cephalosporin. Before taking medicine, you must ask if there is any allergic history, check the results of skin test, and take medicine only if the skin test is negative; If the skin test is positive, it is forbidden to use it, and it is indicated on the medical record card and wristband. For drugs with large individual differences and easy to cause allergic reactions, patients must also be asked whether they have allergic history before taking them. For example: sulfonamides and so on. When using poisonous hemp, psychotropic drugs and high-risk drugs, it should be checked by two people, and the ampoule should be properly kept after use.
6. When multiple drugs are used at the same time, we must pay attention to the contraindications of drug compatibility.
7, hair medicine, injection, such as patients ask questions, should be checked in time, and correct the rear can perform.
(3), blood transfusion examination:
1, blood sample collection and inspection:
(1) Before blood collection, the patient information must be confirmed, and special labels should be attached to the test tubes.
(2) Medical personnel hold labeled test tubes and check the patient's bed number, name, sex, age, hospitalization number, blood type and diagnosis face to face.
2, blood transfusion examination:
(1) Before blood transfusion, check the date of blood collection, whether there is extravasation of blood bag and the appearance quality of blood to ensure that there is no hemolysis, blood clot and deterioration before use.
(2) During blood transfusion, two medical staff (carrying medical records and blood transfusion records) go to the patient's bedside to confirm the recipient, check the patient's bed number, name, hospitalization number, blood type, blood composition and blood volume, and check the donor number, blood composition and cross-compatibility test results with the patient.
(3) After blood transfusion, check the doctor's advice and blood transfusion information again, post the blood transfusion record (cross matching report) in the medical record, and send the blood bag back to the blood transfusion department (blood bank) for at least 24 hours.
(4), outpatient examination before treatment:
1, carefully check the tooth position before tooth extraction, distinguish between left and right teeth, distinguish between deciduous teeth and permanent teeth, and avoid pulling out the wrong teeth.
2, other departments should carefully check the tooth position before treatment, to avoid wrong teeth.
(5), operation inspection:
1. When picking up the surgical patient, the operating room staff and the nurse in charge of the ward should check the department, ward, bed number, name, gender, hospitalization number, age, diagnosis, name of operation, surgical site and its marks, preoperative medication, intraoperative medication, medical records, and preoperative preparation, and fill in the handover record of the surgical patient.
2, before the operation in accordance with the relevant provisions of the "surgical safety verification system" for doctors, anesthesiologists, operating room nurses tripartite verification.
3. Check the information outside the aseptic package, the sterilization of the sterilization indicator card inside the package, and whether the surgical instruments meet the requirements. Before using all kinds of surgical implants, the label content and expiration date should be checked one by one. After use, paste the information card outside the package, and paste the implant label on the operation inventory record sheet.
4, where the body cavity or deep tissue surgery, preoperative and suture must be counted by the instrument division and the visiting nurse double gauze piece, gauze pad, yarn (cotton) ball, instruments, needles, spools, etc. ; At the end of the preoperative inventory, the visiting nurse must repeat it to ensure the accuracy of the inventory. Items temporarily increased or decreased during operation shall be counted and recorded in the same way. After the operation, check it again and sign it. When the number of items counted is inconsistent, it is not allowed to close the body cavity or change shifts.
5. Any gauze, gauze strips or internal plants that need to be filled in the body due to illness shall be recorded in detail on the operation inventory record sheet, which shall be confirmed and signed by the operator when taken out.
6, surgical specimens, equipment nurses and operators after checking, the operator sign the pathological specimen registration form and inspection.