First, the doctor's advice check system
1, doctor's advice, prescription or treatment, should check the patient's name, gender, bed number and hospitalization number.
2, the doctor's advice to do BANCHA class; The establishment of check the doctor's advice register, daily check the registration, copy the doctor's advice and check must be signed.
3, temporary doctor's advice record execution time and signature, before the execution of the doctor's advice in doubt must ask.
4, rescue critically ill patients, the doctor's oral orders, the executor must be repeated before execution. Keep the used empty ampoule, and it must be inspected by two people before it can be discarded.
5, after completing the doctor's advice, must be checked by the second person.
6, the head nurse check the doctor's advice 1-2 times a week.
Two, medication, injection, infusion inspection system
1. Before taking medicine, injection and infusion, the system of "three checks and ten pairs" must be strictly implemented, that is, bed number, name, sex, age, drug name, dosage, concentration, time, usage and expiration date.
2. Check whether the quality of drugs, aqua and tablets has deteriorated before taking drugs; Whether there are cracks in ampoules and infusion bottles; If the validity period and batch number do not meet the requirements or the label is unclear, they shall not be used.
3. After dispensing, it must be checked by a second person before implementation.
4. For allergic drugs, you should ask whether you have allergic history before taking the medicine. When using drugs with toxic, anesthetic and severe limitation, after repeated inspection, keep empty safety bottles after use. When giving a variety of drugs, we should pay attention to whether there are compatibility taboos.
5, medicine, injection, infusion, such as patients with questions, should be found out in time, before implementation.
Third, the blood transfusion inspection system
1, check the date of blood collection, blood clots, blood stasis, and blood bottles (bags) for cracks.
2. Check whether the blood transfusion form is consistent with the name and blood type of the blood donor on the label of blood bag (bottle), whether the blood bag (bottle) and blood volume are consistent, and whether the cross matching report is agglutination.
3. Check the patient's bed number, name, hospitalization number, blood type, blood bottle and blood volume.
4, cross matching report before blood transfusion must be checked by two people rear can perform.
5, after blood transfusion, should keep the blood bottle or blood bag, so that inspection when necessary.
Fourth, the operating room check system
1, pick up the patient and check the subject, bed number, name, sex, diagnosis, operation name, preoperative medication, drug sensitivity test and blood matching report.
2, before the operation, must check the name, diagnosis, surgical site, anesthesia method and anesthesia medication.
3, where the body cavity or deep tissue surgery, before the operation to count all the dressings and instruments and suture.
4, intraoperative specimens should be properly placed, storage, timely inspection according to the doctor's advice.
Five, pharmacy inspection system
1. Pharmaceutical professionals must make "four checks and ten pairs" when preparing prescriptions. Investigator, subject, name and age; Check drugs, check the name, specification, quantity and label of drugs; Look up the contraindications of compatibility and discuss the characteristics, usage and dosage of drugs; Check the rationality of clinical diagnosis medication.
2, drugs should indicate the patient's name and drug name, usage and dosage.
3. When prescribing drugs, patients or their families should be given corresponding medication instructions and guidance according to the drug instructions or prescriptions, including the usage, dosage and precautions of each drug.
Six, blood bank inspection system
1, blood matching and other inspections must strictly check the patient's specimens (name, ward, bed number, hospitalization number, name and number of blood donors). If there is any ambiguity or mistake, please ask the applicant to correct it. Undergraduate personnel shall not be altered.
2, blood type identification and cross matching test, should implement the system of positive and negative blood type identification of patients and blood donors, as well as the system of matching and sending blood. Blood matching must be repeated when a single person is on duty.
3, hair blood, blood * * * check the subject, ward, bed number, name, blood type, cross matching test results, blood bottle number, blood collection date, blood quality.
Seven, clinical laboratory inspection system
1, when taking samples, check the patient, bed number, name and inspection purpose.
2, when collecting specimens, check the subjects, name, gender, bed number, specimen quantity and quality.
3. During inspection, check whether the reagents, articles, inspection sheets and specimens are consistent. Whether the collected specimens meet the inspection requirements, and those that do not meet the requirements should immediately contact the department to keep them again.
4, after the inspection, check whether there are omissions in the purpose and results, for special results, timely review or contact the clinic.
5, send a report, check the department, ward.
Eight, pathological examination system
1, check the unit, name, sex, serial number, specimen and stationary liquid when collecting specimens.
2, production, check the specimen number, type, slice number and quality.
3, diagnosis, examination number, specimen types, clinical diagnosis, pathological diagnosis.
4. Check the subjects and bed number when sending the report.
Nine, radiology examination system
1, check the subject, bed number, name, age, film number, location and purpose.
2, treatment, check the subjects, bed number, name, location, condition, time, angle dose.
3. Check the subjects and bed number when sending the report.
X. physical therapy examination system
1, various treatments, examination objects, bed number, name, location, type, dosage, time and skin.
2, low frequency processing, and check the polarity, current, frequency.
3, high frequency processing, and check the body surface, the body with and without metal anomalies.
4. Before acupuncture treatment, check the quantity and quality of needles. When taking needles, check the number of needles and see if there are any broken needles. ten
A, supply room inspection system
1. When preparing the set, please check the name, quantity, quality and cleanliness.
2. Please check the name and disinfection date when sending the set.
3. When collecting sets, check the quantity, quality and cleaning. ten
Second, the functional departments and other special inspection room inspection system
1, inspection object, bed number, name, gender and inspection purpose.
2, diagnosis, check the name, number, clinical diagnosis, test results.
3, send a report, check the client, ward.
The implementation process of inspection system is as follows
First, check the infusion bottle:
1, pick up the infusion bottle and clean the bottle body;
2. Rotate the bottle cap and check whether the bottle cap is loose;
3. Check the bottle for cracks and damage;
4. Check the drug, concentration, dosage, batch number and expiration date on the label;
5. Turn the bottle upside down and check the transparency, discoloration, impurities and turbidity of the solution. The attending physician should fill in the blood transfusion application form carefully, and fill in the patient's name, gender, age, medical record number, department, ward, bed number and other patient identity information. , accurately fill in the patient's blood type, carefully fill in the clinical diagnosis, blood transfusion indications, accurately fill in the past blood transfusion history, whether the pregnant woman is pregnant, which pregnancy is which, the patient's main blood test indicators, as well as the blood components and input volume to be input. Before blood transfusion, two medical staff should check the contents of cross matching report and blood bag label, and check whether the blood bag is damaged, leaked and the blood color is normal. Blood transfusion is only allowed if it is accurate. During blood transfusion, two medical staff brought medical records to the patient's bedside to check the patient's name, gender, age, medical record number, bed number and blood type. And confirm that it is consistent with the blood matching report. After another blood test, use a blood transfusion device that meets the standards. In the process of blood transfusion, we should slow down first, then adjust the infusion speed according to the condition and age, and closely observe whether the recipient has any adverse reactions to blood transfusion. If there is any abnormality, it should be handled in time, and the inspector should identify and accurately check the patient's identity according to the laboratory test sheet. Check the blood sample carefully according to the inspection list. The patient's blood type is positive and negative, and one person is on duty and the other is on duty. Ensure the accuracy of blood group identification results, the accuracy rate is 100% and the error rate is 0%.
What are the core nursing systems?
Core nursing system:
1, nursing quality management system;
2. Ward management system;
3, rescue work system;
4. Graded nursing system;
6, nursing duty, succession system, inspection system:
Legal basis:
specification for clinical transfusion technology
second
We must protect and rationally use blood resources, avoid waste and put an end to unnecessary blood transfusion.
essay
Clinicians and transfusion medical technicians should strictly grasp the indications of blood transfusion and correctly apply mature clinical blood transfusion techniques and blood protection techniques, including component blood transfusion and autologous blood transfusion.
Article 4
Hospitals above the second level should set up an independent blood transfusion department (blood bank), which is responsible for the technical guidance and implementation of clinical blood use, and ensure the implementation of scientific and reasonable blood use measures such as blood storage and blood matching.