Nursing core system:

①Doctor’s order checking system:

Doctor’s orders should be checked every shift and daily, including the order form and execution Cards, various signs (diet, level of care, allergies, isolation, etc.), and a general inspection registration book. Medical orders processed by a single line shift will be checked by the next shift. After each medical order is processed, it should be checked and signed. Temporarily executed medical orders must be verified by a second person before they can be executed. The execution time is recorded and signed by the executor.

The oral medical order issued by the doctor when rescuing the patient must be repeated aloud by the executor, and it can only be executed after the doctor has verified that it is correct; after the rescue is completed, the doctor will reissue the medical order and sign it; the ampoule will be kept for verification again after the rescue. Doubtful medical orders must be verified before execution

②Check system for dispensing medicine, injections, and infusions:

The "three Check eight to one attention." When preparing medicines, check whether the medicines are within the validity period and whether the labels are clear; whether the solutions and tablets have deteriorated; whether the ampoules and injection bottles have cracks; whether the sealed aluminum caps are loose; whether the infusion bottles (bags) are leaking; whether the medicines are leaking; Check whether the liquid is turbid or flocculent. Any item that does not meet the requirements may not be used. After preparing the medicine, it must be verified by a second person before execution.

Empty ampoules must be kept for reference after use of anesthetic drugs, and at the same time, register and sign in the drug and anesthetic drug management record book. When using multiple drugs, pay attention to whether there are any incompatibility. When dispensing medicine, injections, or infusions, if the patient raises any questions, they should check them in time and confirm that they are correct before execution. After adding medicine to the infusion bottle, the bed number, name, main drug name, and dosage should be noted on the label, and an empty ampoule should be left behind for verification by another person before use.

③ Blood transfusion checking system:

Cross-matching blood checking system. Blood check system When taking blood, carefully check whether the name, gender, serial number, blood transfusion quantity, blood type, etc. on the blood bag are consistent with the cross-matching report form to ensure accuracy. Check the expiration date and appearance of the blood to ensure compliance with regulatory requirements. Blood transfusion process verification system.

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④ Sterile item checking system:

Before using sterilized items and disposable sterile items, Check whether the packaging and containers are tight, dry, and clean, and check whether the sterilization date, expiration date, and sterilization effect indication labels meet the requirements. If items are found to be expired, damaged in packaging, unclean, damp, or not sterile, use is prohibited. When using activated sterilization items, you should check the opening time, quality of the items, tight packaging, and whether there is contamination.

The records of the issuance of disposable sterile items in the disinfection supply room should be traceable. The record content includes the item’s delivery date, name, specification, quantity, manufacturer, production batch number, sterilization date, expiration date, etc. The department designates a dedicated person to be responsible for the collection and storage of sterile items. Regular inventory, classified storage, and timely inspection. Ensure that the outer packaging of the product is tight and clean, and that the sterile items are free of moisture, mildew, and expiration.

⑤Surgical safety verification system:

Before the patient enters the operating room, the person receiving the patient in the operating room shall check the patient's department, bed number, hospital number, name, gender, Diagnosis, name and site of surgery, blood matching report, preoperative medication, drug allergy test results, imaging data, etc. Surgical patients should wear identification tags and are not allowed to bring valuables, dentures, etc. into the operating room.

After the patient enters the operating room, he must be escorted by three parties (hereinafter referred to as the three parties): a qualified surgeon, an anesthesiologist and an operating room nurse (hereinafter referred to as the three parties), respectively before the anesthesia is administered, before the operation begins and before the patient leaves the operating room. ***The patient’s identity, surgical site, etc. will also be verified and signed.

The verification of intraoperative medication shall be made by the operating surgeon or anesthesiologist according to the circumstances and the corresponding records shall be made, and the operating room nurse shall be responsible for verification. For any body cavity or deep tissue surgery, it is necessary to check whether the number of gauze pads, gauze, suture needles, instruments, etc. are consistent with the preoperative number before and after closing the body cavity. The specimens removed during surgery will be checked by the hand-washing nurse and the surgeon, and then the surgeon will fill in a pathological examination form and submit it for inspection, and then register and hand over it.

Reference materials/baike.baidu.com/item/Nursing Technology EFBC88 Volume 1 EFBC89/12371614"target="_blank"gt; Baidu Encyclopedia--Nursing Technology