Article 4 Give a blue warning to those responsible for medical defects.
(1) Defects of medical documents
1. The outpatient (emergency) doctor failed to write the outpatient (emergency) medical record on time, or the record was incomplete.
2, the patient did not cooperate with diagnosis and treatment, refused to diagnosis and treatment or automatic forced discharge and other special circumstances recorded in the entry (emergency) medical records or hospital medical records.
3. No history of drug allergy was recorded in outpatient (emergency) medical records and inpatient medical records, and no history of blood transfusion was recorded in blood transfusion patients.
4. Records of admission, first visit, rescue, preoperative discussion (preoperative diagnosis), operation and anesthesia were not completed within the specified time.
5. Failing to sign all kinds of informed consent forms stipulated by the hospital with patients in time, or lacking goods and funds, failing to fill them in in time and not signing them.
6, large and medium-sized surgery without preoperative discussion, or lack of necessary auxiliary examination report, or no preoperative summary, intraoperative matters needing attention and postoperative observation points.
7. Intraoperative records are inaccurate and incomplete, and the description of intraoperative positive findings is not detailed, or intraoperative accidents and mistakes are not truthfully reflected, or even falsified and concealed in the records.
8. For critically ill patients, the "Notice of Critical Illness" was not issued to their families in time, or there was a lack of records of talking with their families and signing them, or there was a record without the signature of their families.
9. Who decided to transfer the patient? The attending physician didn't write the transfer record.
10. For patients who automatically ask for discharge, the discharge record is too simple, and there is no discharge doctor's advice and related precautions, and there is no signature of the patient himself or the legal representative and the signature of the superior doctor.
1 1. The case of accidental death was not discussed in time, nor was it reported to the medical department or the chief administrative officer.
12. The case has been seriously altered, the writing is wrong, or important medical contents of medical records are missing, or the case and other materials are missing or lost.
(2) Diagnosis and treatment of nursing defects
1. The outpatient (emergency) doctor did not ask the superior doctor for a follow-up visit to the patient who was still difficult to diagnose after three visits.
2, critically ill patients arrived in the emergency department, did not start rescue within 3 minutes.
3. The outpatient (emergency) doctors failed to implement the responsibility system for the first-visit doctors of critically ill patients, and the first-visit doctors failed to treat the corresponding departments of multidisciplinary patients according to the main conditions of patients.
4. Outpatient (emergency) doctors open "hospitalization certificate" without looking at patients or ward doctors open medical orders without looking at patients.
5. For critically ill patients, the patient and the medical (technical) department of the medical technology department did not arrive at the scene within 10 minutes after receiving the invitation.
6. The consultant fails to write the consultation record according to the regulations or fails to conduct "telephone consultation" or "case consultation" consultation on the patient.
7, tertiary physician rounds are not timely or record content is not standardized.
8. The second-line or third-line personnel on duty in the department are not clear or the communication tools are not smooth or can not be put in place in time.
9. When the patient's condition suddenly deteriorated and the initial treatment effect was not good, the superior doctor was not consulted in time.
10, for difficult and critical cases, case discussion or inter-departmental consultation was not submitted in time.
1 1. The doctor's order needs to be executed immediately, and the nurse is not clear, which leads to the delay in execution.
12, the bedside double shift was not carried out for critically ill patients, or the condition and handling items of critically ill patients were not written into the handover record, or there were cases of missing delivery and connection.
13. High-risk and difficult elective surgery, which was not reported to the medical department before operation.
14. The anesthesiologist lacked the records of preoperative and postoperative anesthesia visits, or the patient did not consult the patient within 24 hours after returning to the ward.
15, the surgeon failed to check the patient in time after operation, or there was no record of the third-level doctor's rounds within 3 days.
16, the patient did not observe carefully after operation, and failed to find bleeding and abnormal oozing in time.
17, the medical staff caused insufficient preoperative preparation and delayed the operation.
18. The check system before blood transfusion is not implemented, or the check items are incomplete, or the informed consent form is not standardized.
19. The nurse did not execute the doctor's advice correctly or violated the system of "three checks and seven pairs".
20, wrong hair, leakage of drugs, but did not cause consequences, and cause complaints from patients.
2 1. There are errors in usage, contraindications to medication and compatibility, or the dosage exceeds the limit without indicating, but it has not caused personal injury to the patient.
22. Use narcotic drugs, toxic drugs for medical use, psychotropic drugs and radioactive drugs in violation of relevant regulations.
23. When taking a body fluid sample, the wrong sample was taken, the wrong label was attached, and the anticoagulant was added by mistake. The collection volume was not enough due to non-patient reasons, so it was necessary to re-collect.
24. The concept of aseptic operation is not strong, the disinfection and isolation system is not implemented or the method is improper, and there are hidden dangers of cross-infection among patients in the hospital.
25, late reporting, omission of infectious diseases, or in case of serious work-related injuries, major traffic accidents, a large number of poisoning, etc. Hospitals must mobilize to rescue patients and cannot report them in time.
26, due to the need of treatment and illness allows need to change majors, transferred out of the department did not contact in time or transferred to the department to delay the transfer without justifiable reasons.
27, other did not cause personal injury consequences, but there are patient complaints of diagnosis and treatment behavior.
(C), medical safety defects
1, rescue drugs and materials were not replenished and replaced in time, and the accounts and materials did not match.
2, the supply of expired items, expired sterilization equipment or unqualified materials.
3, emergency equipment, equipment failure, or power supply, oxygen supply, water supply system is not regularly tested and affect the use, but no consequences.
4. The medical department neglected the inspection and maintenance of instruments and equipment, which led to the distortion of inspection results.
5, the medical department neglected to check, specimens or items, parts is wrong.
6. Omission, misstatement of inspection results or loss of inspection application forms and results reports.
7, blood, urine, stool and other missing specimens.
8, special inspection specimens, pathological specimens retained (save) time is shorter than the prescribed time.
9. When the test results are inconsistent with the clinic or suspicious, they failed to contact the clinical department in time and put forward the re-inspection; Actively report the positive results beyond the inspection purpose.
10, the pharmacy department failed to find out the improper usage, contraindications, compatibility contraindications and excessive dosage of drugs in the prescription in time.
(D), medical ethics defects
1, indifferent attitude and rude language.
2. Raise yourself and belittle others.
3, gossip, deliberately provoke contradictions.
4, dereliction of duty, AWOL.
5. Exaggerate the curative effect and underestimate the bad prognosis.
6, medical staff in the process of diagnosis and treatment for patients with surgery, medicine, chat, mobile phone.
7. Irresponsibly explain the work of other medical staff, resulting in misunderstanding of patients or their families.
8. Other medical ethics issues.
Article 5 Give a yellow warning to those responsible for medical defects.
(1) Failing to complete important documents such as hospital medical records, first-visit records and operation records within the specified time, or failing to complete emergency rescue records for more than 6 hours, which may lead to medical disputes and complaints.
(two), non special and difficult patients, not diagnosed in time (more than 72 hours) or not timely determine, correct, supplement the treatment plan, delay the treatment caused by patients' complaints.
(3) The third-level doctors' rounds are not timely, especially the superior doctors' rounds are not timely, resulting in complaints from patients.
(4), by the medical association appraisal or court judgment, although it does not constitute a medical accident, but there is a certain fault or mistake, which has caused economic losses to the hospital, the amount is below 6.5438+0 million yuan (including 6.5438+0 million yuan).
(five) within one year, he was given two blue warnings of medical defects.
Article 6 Give a red warning to the person responsible for medical defects.
(a), identified as a medical accident by the medical association or the people's court.
(2) medical disputes caused by various "inaction" factors, and the responsible person has serious negligence. Although it is not recognized as a medical accident, it has a bad influence, resulting in damage to the reputation of the hospital.
(three) due to the fault of the responsible person, resulting in medical defects, through the mediation of the doctor-patient coordination office, to give patients economic compensation, the amount of more than 654.38+00 thousand yuan.
(four), a serious medical ethics incident, was exposed by the news media, causing damage to the reputation of the hospital.
(five) within one year, twice by the yellow warning of medical defects.
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