1, doctor's advice checking system

1), the doctor's advice must be double-checked before execution, and the doctor's advice must be checked once a day.

2), copy the doctor's advice must indicate the date, time and signature, and checked by another person. The person who copied the doctor's advice and the person who checked it must sign.

3), temporary execution of the doctor's advice, need to be checked by the second person, before execution, and record the execution time, the executor's signature.

4) When rescuing patients, the doctor gives oral orders, and the executor must repeat them loudly, and then execute them. After the rescue, the doctor should fill in the orders and sign them. The ampoule should be checked again after the rescue.

5), the doctor's advice in question must be asked before execution and copying.

2, medication, injection, infusion inspection system

1), "three checks and seven pairs" must be strictly implemented before taking medicine, injection and infusion. Third inspection: inspection after drug release; Check before taking medicine, injection and disposal; Inspection after injection and treatment. Seven pairs: bed number, name, drug name, dosage, concentration, time and usage.

2) Check the quality of drugs before dispensing, pay attention to the deterioration of aqueous solution and tablets, and the cracks in ampoules and injection bottles; Whether the sealing aluminum cover is loose; Whether the infusion bag leaks; Whether the liquid medicine is turbid or flocculent. Expired drugs, expiration date and batch number do not meet the requirements or the label is unclear, and shall not be used.

3), after placing medicine must be checked by a second person, before execution.

4), allergic drugs, should ask whether there is a history of allergies before using; When using toxic, narcotic and psychotropic drugs, the Regulations on the Administration of Narcotic Drugs and Psychotropic Drugs of Class I in Medical Institutions (Wei Yao [2005] No.438) should be strictly implemented. Nurses should go through repeated checks and return ampoules to the pharmacy in time after use; When giving a variety of drugs, we should pay attention to whether there are compatibility taboos. At the same time, the nursing department should standardize and improve the drug operation guide and drug compatibility taboo list according to the drug instructions.

5), drugs, injections, patients, if in doubt, should be checked in time, check the rear can be executed.

6) After the infusion bottle is filled, the label should indicate the name and dosage of the medicine, and an ampoule should be left for another person to check before use.

7), strictly implement the bedside double check system.

3, surgical patients check system

1), when picking up patients in the operating room, check whether the subjects, hospitalization number, bed number, name, wristband, gender, age, diagnosis, name and location of operation (left and right) and their marks, preoperative medication, eight results before blood transfusion, drug allergy test results are consistent with the drugs and articles (such as ct and X-ray films) brought by the operation notice and operation doctor's advice. Evaluate the patient's overall situation and skin condition, and ask about allergic history.

2), surgical nurses check whether the surgical instruments are complete, and whether the categories, specifications and quality of various supplies meet the requirements. Whether the patient's posture is correct, expose the surgical field as much as possible to prevent bed fall and pressure sore.

3) Before the operation, the operator should check the department, hospital number, bed number, name, wristband, gender, age, diagnosis, surgical site, anesthesia method and medication, blood matching report, etc. When opening the aseptic bag, the hand washing nurse should check whether the chemical index card in the bag is up to standard. All hand-washing nurses and visiting nurses must strictly check the body cavity or deep tissue surgery before and after the operation, sing out the number of instruments, gauze pads, gauze and sutures in the operation bag, and the visiting nurses will immediately record and sign the operation nursing record. Before and after the operation, the number of instruments and articles in the bag is consistent. After verification, the surgeon can be informed to close the surgical incision to prevent foreign bodies from staying in the body cavity.

4), surgical resection of biopsy specimens, should be checked by hand washing nurses and operators, establish a specimen registration system, the specialist is responsible for the examination of pathological specimens.

4, blood transfusion check system According to the requirements of the Ministry of Health's "Technical Specification for Clinical Blood Transfusion", the cross-matching check system, blood collection check system and blood transfusion check system were formulated.

1), blood cross matching examination system

(1), carefully check the cross matching list, patient blood type test list, patient's bed number, name, gender, age, disease area code and hospitalization number.

(2), blood should have two nurses (a nurse on duty, should be assisted by the doctor on duty), one blood, one person to check, after check.

(3), after blood (cross) must stick a bar code on the test tube, and write down the ward (number), bed number, patient's name, handwriting must be clear, easy to check.

(4), blood samples pump enough blood as required, can't be extracted from the veins of limbs, rehydration.

(5) when there is any doubt about the laboratory test sheet and the patient's identity during blood drawing, it should be checked with the competent doctor and the nurse on duty. Wrong papers and labels can't be modified directly, and correct papers and labels should be filled in again.

2), blood check system When taking blood from the blood bank, carefully check the name, gender, bed number, blood bag number, blood type, blood transfusion volume, blood validity period and preserved blood appearance, which must be accurate; Blood bags should be placed in a treatment tray or a clean container covered with sterile towels for recycling.

3), blood transfusion check system ①, patient check before blood transfusion: two medical staff must check the patient's bed number, name, hospitalization number, blood type and blood volume on the cross-matching report, and check the name and number of the blood donor and the results of the cross-matching test. Check whether the name, number and blood type of the label on the blood bag are consistent with the blood matching report. If they are consistent, proceed to the next step.

② Inspection materials before blood transfusion: Check the blood collection date of the blood bag, whether the blood bag has extravasation and the appearance quality of the blood, and ensure that there is no hemolysis, blood clot or deterioration before using it. Check whether the blood transfusion instruments and needles used are within the validity period. After the blood is taken out of the blood bank, do not shake it evenly, do not heat it, do not put it in the refrigerator for quick freezing, and do not leave it at room temperature for too long.

(3), blood transfusion, by two medical staff (carrying medical records and cross matching list) * * * to the patient's bedside to check the bed number, ask the patient's name, check the bedside card, ask the blood type, confirm the recipient.

(4) Before and after blood transfusion, flush the blood transfusion pipeline with intravenous saline. When the blood of different donors is continuously infused, after the first bag of blood is exhausted, the transfusion apparatus is washed with intravenous saline, and then another bag of blood is continuously infused. During blood transfusion, closely observe the transfusion reaction of patients.

(5) After the blood transfusion operation is completed, check the doctor's advice, patient's bed number, name, blood type, blood matching list, blood bag label, blood number, blood donor's name and blood collection date again, and sign after confirmation. Stick the record sheet (cross-matching report) in the medical record and send the blood bag back to the blood transfusion department (blood bank) for at least one day.

5, diet inspection system

1), after checking the doctor's advice every day, based on the diet list, check the patient's dietary signs before going to bed, check the bed number and diet type, and publicize the clinical significance of dietotherapy to patients.

2) Before distributing the diet, check whether the diet list is consistent with the type of diet.

3) Check again at the patient's bedside before meals.

4) For fasting patients, eye-catching signs should be set up at the end of eating and when staying in bed, and the patients or their families should be informed of the scheduled fasting time.

5) For patients who have restricted their diet due to illness, the food sent by their families must be checked by medical staff before they can be eaten.

Inheritance system

1, the personnel on duty should strictly abide by the nursing management system, obey the arrangement of the head nurse, stick to their posts, perform their duties, and ensure the accurate and timely treatment and nursing work.

2, before the succession, the main nurse should check the implementation of critically ill patients' doctor's advice and nursing records, focusing on patrolling dangerous and new patients, and arrange the nursing work during the succession.

3, each shift must be handed over on time, the successor to the department in advance 1.5 min, read the nursing records, don't pick up the handover (the number of patients is not allowed, the condition is unclear, the bed is unclean, the patient's skin is unclean, the pipe is blocked, the treatment is not completed, and the number of items does not match).

4. The personnel on duty must complete all the records and work of the class before taking over, handle the items and prepare materials for the successors, such as disinfection dressings, test tubes, specimen bottles, syringes, standing equipment, clothes, etc. In order to facilitate the work of the successor. In case of special circumstances, you must explain it in detail before leaving your job and get on well with your successor.

5, the early shift, reported by the night nurse, all staff should listen carefully to the night shift * * * buckle led by the head nurse patrol ward, bedside handover condition and ward management.

6. The contents of the succession include:

(1) The total number of patients, the number of discharged patients, the number of people who changed careers, transferred to other hospitals, delivered babies, operated and died, and the changes of illness/human feelings and psychological state before and after the new hospital, patients, rescued patients, major surgery or special examination and treatment, abnormal behavior and suicidal tendency.

(2) The execution of doctor's orders, intensive care records, collection and disposal of various test specimens are completed, and the unfinished work should be explained to the successor.

(3) check the coma, paralysis and pressure ulcers and other critically ill patients, as well as the completion of basic nursing and the patency of various catheters.

(4) the quantity and technical status of precious, highly toxic, hemp, psychotropic drugs and rescue drugs, instruments and appliances. , full name

7, succession * * * cooperate with patrol to check whether the ward is clean, neat and quiet and the actual situation of each work.

8, the rest of the shift in addition to detailed succession, should be with ward * * * member, bedside succession.

9, such as found in the succession of illness, treatment, equipment, goods account is not clear, should immediately query. The successor shall be responsible for the problems found during the succession; After the succession, the successor shall be responsible for the mistakes, accidents or loss of articles caused by unclear succession.

10, hand-over report (nursing record) should be written neatly, clearly and emphatically. The contents of nursing records are objective, true, timely, accurate, comprehensive, concise and coherent, and medical terms are used. When training nurses or practicing nurses write nursing records, the teaching nurses are responsible for revising and signing them.