1. The medical history, physical examination and course records are wrong or important records are omitted, which directly leads to misdiagnosis or mistreatment, or delays rescue, resulting in serious consequences.

2. The competent physician failed to timely observe and record the details of the patient's illness evolution and treatment, resulting in serious consequences.

3. The superior doctor rounds or consultation guidance, no doctor's advice within 24 hours.

Line, and there is no record of the execution reason, causing serious consequences.

4. The medical record lacks the important medical activity records specified in this specification, or fails to complete all kinds of medical activity records within the time limit specified in the medical record writing specification, which affects the diagnosis and treatment and causes serious consequences.

5. Medical activities that require patients' consent, lack of "informed consent" or those who sign the consent do not meet the requirements of the specification, leading to serious consequences of major doctor-patient disputes.

6. Electronic medical records include outpatient (emergency) electronic medical records, inpatient electronic medical records and other electronic medical activities.

Dynamic record, lack of operator's exclusive identity, operator's electronic signature, and lack of electronic signature when modifying.

Confirm that all previous modification traces have not been retained, and the accurate modification time and modifier information have not been marked.

The child's medical record is basically standardized, which leads to serious consequences.

7. The whole process of interventional diagnosis and treatment is not recorded in the medical record (written according to the operation specification), and there is no record of interventional complications or analysis of the cause of death. Postoperative interventional therapy is ineffective, and there is no record of follow-up diagnosis and treatment, which leads to serious consequences.

8. Deliberately damaging, tampering with or forging medical activity data (including electronic records of medical activities), resulting in untrue medical records.

Second, the diagnosis of serious defects:

1. Misdiagnosis of major diseases directly leads to serious consequences.

2. The patient's condition deteriorated, and the lower-level doctors failed to report it in time, and the higher-level doctors failed to give timely guidance, which directly led to serious consequences.

3. The implementation of invasive diagnosis operation error or violation of operating procedures, medical departments appear false report, false inspection, omission, resulting in serious consequences.

4. All kinds of important specimens are lost, not sent or delayed, which leads to delayed diagnosis and directly leads to serious consequences.

Third, the handling of serious defects:

1. Wrong treatment (including drug or non-drug, invasive or various non-invasive treatments) directly leads to serious consequences.

2 clear diagnosis of major diseases and their serious complications, but not timely development or implementation of treatment programs, directly leading to serious consequences.

3. Violating the principle of drug use, using drugs without indications or using fake or inferior drugs for treatment, resulting in serious consequences.

4. Violating the laws and regulations on the management and use of drugs and narcotic drugs, and abusing drugs and narcotic drugs to make patients addicted.

5. Violation of the management measures for clinical blood use and the technical specifications for blood transfusion, unqualified blood source, or collection of blood for clinical use, resulting in serious consequences.

Four, surgery, anesthesia serious defects:

1. Wrong surgical object or posture, wrong surgical method, unclear surgical indications and inadequate preoperative preparation directly lead to serious consequences.

2. Improper anesthesia (indications, drug selection, drug dosage, anesthesia methods and surgical methods, etc. ) directly lead to serious consequences.

3. Those who violate the operating rules in the operation and cause serious consequences.

4. Patients left instruments, gauze and other foreign bodies after operation, causing serious consequences.

5. Disability surgery, new surgery or new anesthesia methods, lack of preoperative discussion records, or lack of the signature of the department director, or lack of the approval of the competent leader, resulting in serious consequences.

6. Non-difficult cases delayed diagnosis, or missed the best operation opportunity without finding the deterioration in time, resulting in serious consequences.

7. The operators of Class Ⅲ or Ⅳ operations did not have the corresponding title of "Code for Classification and Approval Authority of Operations in General Hospitals at All Levels in Hunan Province", which directly led to serious consequences.

Five, rescue serious defects:

1. The principle of rescuing critically ill patients is wrong, or the drug or non-drug treatment measures are wrong, which directly leads to serious consequences.

2. The patient's condition deteriorated, and it was not found in time to miss the best time for rescue, which caused serious consequences.

3. The routine monitoring and rescue equipment in ICU, operating room, emergency department and ward is not kept in good condition or used improperly, which delays the rescue opportunity and leads to serious consequences.

Six, the serious defects of hospital infection:

1. unqualified disinfection and sterilization of medical supplies directly leads to cross-infection in the hospital, leading to serious consequences.

Seven, there are serious defects in the clinical application of antibacterial drugs:

1. Antibacterials have been clearly used for pure virus infection.

2. Class I incision operation has no high risk factors and no clinical basis for infection.

3. Failure to use antibacterial drugs according to the dosage or administration method specified in the instructions leads to serious adverse reactions such as drug poisoning and organ function damage.

4. Non-restrictive antibiotics are not the first choice for preventing infection and treating mild or local infection (except when the immune function is low and infected or the cultured pathogens are only sensitive to restrictive antibiotics).

5. The use of super antibacterial drugs without professional technical consultation, or by a doctor who has no right to prescribe.

6. Non-emergency situations, such as rescuing dying patients and doctors using antibiotics, or emergency situations, such as rescuing dying patients and doctors using antibiotics, were not recorded in detail.

7. There are no indications for the combined use of antibacterial drugs, or the indications for the combined use of antibacterial drugs are not recorded in detail.

8. There is no special reason for using fluoroquinolones in perioperative preventive medicine.

Eight, clinical pathway management has serious defects:

1. The diseases declared by the hospital and confirmed by the provincial health administrative department to implement clinical pathway management meet the access standards but have not been implemented.

2. During the implementation of the clinical pathway, the steps were not carried out in strict accordance with the diagnosis and treatment process and time limit determined by the pathway and recorded, without explanation.

3. In the process of implementing clinical pathway management, it is necessary to adjust the diagnosis and treatment pathway according to the change of illness. Because it was not found in time or reported to the superior doctor, it was not given timely guidance and adjustment, which affected the diagnosis and treatment.

Nine, there are serious defects in the quality of hospital electronic medical records:

1. The entry of electronic medical records is untrue, inaccurate, objective, untimely and incomplete, which affects the diagnosis and treatment of patients and causes serious consequences or certain social impact.

2. The electronic medical record is lost or incomplete, which affects the judgment, analysis or reliability of the illness. Surgical records, important consultation records and important examination records are submitted for preservation without the examination of the surgeon or superior doctor, causing serious consequences.

3. Copy the medical records of other patients and appear in the electronic medical records.