Prescription Review Self-inspection Report Fan: County: According to the spirit of the document XXX [20xx] 2 1 "Notice on Printing and Distributing the Work Plan of Centralized Remediation in the Field of Drug Production and Circulation in the County", our hospital conducted a comprehensive self-inspection and self-correction on the drug safety management in our hospital in combination with the actual situation and highlighting the key points. The self-inspection is now reported as follows:
First, strengthen leadership and strictly implement drug safety responsibilities.
On March 10, the hospital set up a leading group for centralized drug safety rectification in the whole hospital, which was composed of the president, vice president, department director and pharmacy staff. The leading group carried out the special rectification of drug safety as a whole, organized the analysis of drug safety situation, and eliminated the hidden dangers of drug safety in our hospital in time.
Two, extensive publicity, and strive to create a good environment for safe drug use.
On March 15, our hospital organized a lecture on drug safety knowledge, which strengthened the publicity and education of rational drug use and basic drug knowledge, so that our staff could firmly establish drug safety awareness, standardize medical behavior, improve drug use level and ensure drug safety.
Three, attach great importance to and actively carry out drug safety self-inspection activities.
On March 25th, our hospital organized an inventory of all drugs in Chinese and Western pharmacies. Inventory items include drug manufacturer, approval number, expiration date and appearance quality. No food, disinfection products, health food and counterfeit drugs were found in the inventory, and no expired drugs, moldy drugs and drugs with excessive chromium content announced by the US Food and Drug Administration were found.
Fourth, standardize drug use and give priority to the use of essential drugs.
The purchase plan of essential drugs used in our hospital will be submitted online through the centralized procurement platform of 00 provinces, which will be uniformly distributed by the bidding enterprises for the distribution of essential drugs in the province, and all drugs will be sold with zero difference rate.
Five, strictly control, strengthen drug quality management.
Check and accept the purchased drugs one by one in strict accordance with the regulations, establish a true and complete record of drug purchase and acceptance, register each batch and each variety in the warehouse, designate a special person to register the indoor temperature and humidity of Chinese and western pharmacies and warehouses every day, do a good job in maintaining the drugs in the warehouse, and store and display the drugs as required. Put an end to quality problems such as mildew, damage, weathering, discoloration and expiration. , and the drug quality responsibility to the person in charge of each position.
Six, raise awareness, strictly implement the rules and regulations.
According to "Prescription Management Measures" and "Guiding Principles for Clinical Application of Antibacterials", our hospital actively promotes the prescription review system, and the quality of hospital prescriptions is regularly reviewed and analyzed by special personnel, and the prescription review results are published through the bulletin board. Double-ranking statistics are made on the consumption of antibiotics by residents every month, and the overuse of antibiotics is checked. Unqualified prescriptions and medical records are included in the year-end assessment, rewards and punishments of various departments.
Prescription review self-inspection report Fan Medical Administration Department of the Ministry of Health:
In order to implement the spirit of the Ministry of Health's Regulations on Management of Hospital Prescription Review (Trial) and the Regulations on Pharmaceutical Affairs Management of Medical Institutions, standardize medical behavior, reduce medical expenses, improve pharmaceutical service quality, ensure drug safety, and effectively control drug quality and price, relevant staff, under the leadership of our hospital, earnestly organized and studied the spirit of superior documents, and achieved remarkable results in clinical rational drug use. The results of our self-examination are summarized as follows:
First, carry out prescription and doctor's advice comments, and summarize the prescription comments.
With the strong support of hospital leaders and the concerted efforts of all departments in the hospital, our hospital set up a prescription review expert group to provide professional technical advice for prescription review, and set up a prescription review working group in the pharmacy department to be responsible for the specific work of prescription review, regularly publish prescription review results and notify unreasonable prescriptions. The prescription review team randomly checks 100 outpatient prescriptions and 30 inpatient medical records every month, reviews the relevant regulations and parameters of the extracted prescription medical records according to the prescription management measures, makes statistical analysis on irrational drug prescriptions combined with the drug instructions and pharmacopoeia, and informs the hospital of the prescriptions and medical records with problems, so that doctors in various departments can conduct self-examination and self-correction under the guidance of the department director.
What are the main problems in our hospital through persistent comments, summaries and informed criticism on monthly prescriptions and medical records? Incomplete clinical diagnosis? 、? Clinical diagnosis does not match the medication? 、? Writing is not standardized? Problems have been significantly improved, and the qualified rate of prescriptions in the last two months has increased from 78% to 95% now.
Second, the pharmaceutical affairs management system is sound and the work is in place.
1. There is a hospital pharmacy management and drug treatment committee, which is composed of hospital leaders, medical department, hospital infection department, pharmacy department and clinical department directors, all of whom have advanced technical qualifications.
2. There are 23 professional technicians in the pharmacy department of the hospital, which are not up to standard, including 2 assistant pharmacists, 9 pharmacists in charge, 6 pharmacists and 5 pharmacists. The person in charge of pharmacy department is the deputy director pharmacist, with a bachelor's degree. Clinical pharmacists 1 person (not up to standard).
3. Our hospital implements the national laws and regulations on drug management and establishes relevant systems on drug management.
4. The hospital set up an ADR leading group and an ADR working group, formulated the working system and made work records.
5, the medical department has a full-time staff responsible for participating in the administrative affairs management related to drug treatment in our hospital.
6, strictly implement the relevant provisions of the centralized bidding and purchasing management of drugs in Shanxi Province, according to the bidding directory procurement of drugs. The drugs needed in our hospital are purchased by the Pharmacy Department, and it is strictly forbidden to purchase drugs from illegal channels to ensure the safety of clinical medication.
Three, standardize clinical rational drug use, try to be reasonable, effective, economical and applicable.
1. Formulated the working system, implementation methods and the list of essential drugs for the clinical application management of drugs in our hospital.
2. Formulate the clinical application norms or implementation rules of antibacterial drugs in our hospital, monitor the clinical use of antibacterial drugs and take intervention measures.
3. Conscientiously implement the monitoring and publicity of total drug use, notification of doctors' drug use and evaluation of doctors' rational drug use.
4. Strictly supervise clinical medication and implement the set clinical medication? Red line? (Department drug ratio), no violation, no breakthrough, and promote clinical rational drug use.
The management of clinical application of antibacterial drugs is as follows:
(1) The clinical use of antibacterial drugs shall be managed at different levels, and it is required to follow the Guiding Principles for Clinical Application of Antibacterials, rationally use antibacterial drugs, regularly check and count the actual use of clinical departments, and submit them to the Medical Education Department for notification.
(2) At the same time, as a member of the Antimicrobial Monitoring Network of the Ministry of Health, with the help of this platform, we regularly investigate and analyze the use of antibacterial drugs and implement restrictions on the use of some antibacterial drugs. 20 10 antibacterials accounted for 6.7% of the sum of money used in our hospital.
(3) The bacteria room shall report the common pathogenic bacteria and bacterial drug resistance in the hospital once every quarter.
(4) Formulated the interim provisions for hospitals to control the proportion of drugs in various departments. The hospital announces the control of drug proportion in clinical departments every month, and reports the monthly monitoring situation at the weekly meeting of the hospital, and punishes the over-proportion departments according to the management measures.
(5) The hospital organizes training on clinical rational drug use irregularly every year, and monitors, evaluates and reports the drug use of doctors once a month. The hospital prescription review team conducts spot checks on the drug use of clinical departments and clinicians every month, and implements warning talks and informed criticism for clinicians who use unconventional drugs.
(6) Rational use of drugs by clinicians is an important part of doctors' moral evaluation and medical quality assessment.
Four, the use and management of special drugs
1, strictly implement the relevant provisions of the national management of narcotic drugs and psychotropic drugs, and establish and improve the system of purchasing, storing, keeping and using special drugs.
2. The system of purchasing, acceptance, storage, custody, distribution, use, damage, destruction, loss and theft of narcotic drugs and psychotropic drugs and on-duty inspection has been established.
3. strictly enforce it? Five specialties? Management of narcotic drugs and psychotropic drugs, complete and standardized acceptance records, safe storage and protection measures, special person in charge, double lock, set up special account books for entry and exit, and register special prescriptions. No illegal use or loss occurred.
Problems and improvement measures of verbs (abbreviation of verb).
1, the proportion of pharmaceutical technicians is not up to standard; Clinical pharmacists are not up to standard. The leaders of the hospital attach great importance to it and are prepared to actively introduce pharmaceutical professional and technical personnel to meet the requirements.
2. Our hospital has not established an intravenous drug dispensing center. Hospital leaders have begun preparations for the establishment of an intravenous dispensing center and are currently planning the location of the center.
3. There are still differences between clinical diagnosis and drug treatment in prescription writing. In view of this situation, the medical education department and pharmacy department are going to train doctors on the Prescription Management Measures and common mistakes in prescription writing again to improve the qualified rate of prescriptions.
4. There are still unreasonable phenomena in clinical rational drug use: for example, the proportion of preventive drug use for class I incision exceeds 30% (42% in the third quarter of our hospital); Some patients still take drugs for a long time after class ⅰ incision; The selection starting point of prophylactic drugs for type I incision is higher. In view of this situation, first of all, our hospital took individual talks on the problems found in the self-examination of antibacterial drugs (because the application of antibacterial drugs has been trained for five times) to promote rational clinical use of drugs. Since the special rectification activities of antibacterial drugs were launched, with the joint efforts of doctors in our hospital, the proportion of antibacterial drugs used in our hospital has dropped significantly, and the clinical application of antibacterial drugs has become increasingly reasonable. However, there is still a big gap between some indicators and the requirements of special rectification activities. We will make persistent efforts in the future work to make the use of antibacterial drugs in our hospital more standardized and reasonable.