#report# Introduction With the promotion of market economy, various types of companies have also made great progress, and reporting has become an emerging industry. The following is a compiled self-examination and self-correction report on medical behavior. Welcome to read it!

1. Medical Behavior Self-examination and Self-Correction Report Part 1

1. Medical Quality Management

Our hospital pays close attention to service quality, strictly prevents medical errors, and practices in accordance with the law. , Practice medicine in a civilized manner. The hospital has established a medical quality management leading group headed by Vice President Zhang Jiyue, which regularly checks prescriptions and medical records, provides timely feedback to relevant responsible persons, and supervises the medical quality of the entire hospital. The quality control of various single diseases reaches municipal and district standards.

2. Medical Documents

Strictly abide by the requirements in the "Basic Standards for Writing Medical Records" and write all medical care for patients objectively, truthfully, accurately, timely and completely Documentation.

3. Rules and Regulations

Our hospital has improved and implemented a series of rules and regulations, and improved various management systems, including thirteen core systems, new technology access system, and pharmaceutical management system, public emergency management system, etc. For patients seeking medical treatment, they are required to present their medical certificate and ID card when registering. Inpatients are required to submit copies of both certificates during hospitalization, and check them carefully to prevent impersonation. Strictly grasp the admission standards, follow what can be treated in outpatient clinics, resolutely not be hospitalized, strictly follow the standards for hospitalization, do not arbitrarily lower the hospitalization indicators, and do not delay the hospitalization days.

Our hospital strictly abides by the relevant systems of medical insurance, organizes all medical staff in the hospital to repeatedly and carefully study the relevant policies of medical insurance, and conducts assessment work, linking the assessment results with the distribution of personal interests.

IV. Essential Drug System

Our hospital strictly follows the provisions of the "Essential Drug Catalog" for the examination and treatment of patients undergoing treatment or hospitalization. Every doctor is required to strictly abide by professional ethics and ensure reasonable examination, rational use of drugs, reasonable treatment, and reasonable charging. He can use low-priced drugs instead of high-priced drugs, so as to effectively reduce the medical cost burden of farmers. The drug inventory in the drug library reaches more than 90% of the catalog stipulations. The amount of prescription drugs is strictly controlled. Inpatients should not take more than 3 days of medicines, and discharged patients should not take more than 7 days of medicines. Large prescriptions, favor prescriptions and drug abuse are strictly prohibited, and the number of days of discharge from hospital should not exceed the actual number of days of hospitalization. Conduct inspections strictly in accordance with regulations and resolutely put an end to the phenomenon of one person having medical insurance and the whole family taking medication.

5. Medical Expenses Control

Our hospital charges fees in strict accordance with the charging standards jointly formulated by the provincial, municipal, and district price, health, finance and other departments. Pay close attention to connotation construction, improve service quality, shorten the average hospitalization days of patients, and strictly control hospitalization expenses.

2. Medical Behavior Self-examination and Self-Correction Report Part 2

In order to implement the quality inspection of our hospital’s drugs and medical devices by the Food and Drug Administration and ensure the people’s use of medical devices Safe and effective, standardize drug use and management. The hospital has established a self-examination team headed by the president. In accordance with the "Notice on Effectively Strengthening the Safety Management of Drugs and Medical Devices in Medical Institutions at All Levels" and the "Drug Administration Law" and "Drug Use Quality" issued by the Xiwu Banner Health Bureau Management Standards" and "Standards for Regulating Pharmacies" were self-examined one by one and compared one by one. The self-examination team did a lot of detailed self-examination work. The self-inspection report is as follows:

1. Institutions, personnel and systems:

Our hospital has legal qualifications such as the "Medical Institution Practice License". A drug quality management organization has been established, consisting of the dean in charge, the person in charge of the pharmaceutical and device department, the person in charge of the pharmacy, the quality person in charge, and the purchaser, and the responsibilities of personnel and institutions at all levels have been clarified. At the same time, various quality management rules and regulations have been formulated as a guarantee and are carefully organized and implemented. At the same time, our hospital’s Pharmaceutical Affairs Management Committee and Clinical Rational Use of Antimicrobial Drug Supervision and Steering Group have been established and improved.

Our hospital has established a continuing education and training plan, focusing on training on the "Drug Administration Law of the People's Republic of China", "Regulations on Pharmaceutical Affairs in Medical Institutions", "Regulations on the Supervision and Administration of Medical Devices", " "Guiding Principles for Clinical Application of Antimicrobial Drugs", "Measures for the Management of Clinical Application of Antimicrobial Drugs", "Measures for the Management of Prescriptions", "Special Rectification Activity Plan for Clinical Application of Antimicrobial Drugs in Inner Mongolia Autonomous Region in 20xx" and other laws and regulations, basic principles of ethnic medicine and medical care

On the normative documents issued by the Heqi Health Bureau on strengthening the supervision and management, storage and use of drugs and medical devices to improve the quality of personnel, and further standardize the procurement, acceptance, storage and storage of drugs and medical devices All aspects from storage to use must be strictly followed. Personnel who are engaged in pharmaceutical work and have direct contact with pharmaceuticals must undergo health examinations every year and establish health files to ensure the safety and effectiveness of pharmaceutical use.

2. Procurement and acceptance:

Procurement of drugs shall be carried out in strict accordance with the centralized drug procurement system formulated by the superior health bureau. Drugs are purchased from enterprises with drug production and operation qualifications; drug storage acceptance is strictly carried out in accordance with standard operating procedures, and the quality of purchased drugs and returned drugs are inspected batch by batch in strict accordance with legal quality standards and contract quality terms.

3. Implement the standardized pharmacy management system:

Strictly follow the standards of standardized pharmacies to manage the Mengxi pharmacy and medicine library in the entire hospital.

IV. Drug Storage and Maintenance:

The warehouse is divided into drug warehouse and medical device warehouse. Each warehouse is divided into qualified area, untested area and unqualified area. Each area shall be implemented according to regulations. Color mark management, that is, the qualified area is green, the pending inspection and return area is yellow, and the unqualified area is red. After passing the inspection and acceptance, the special drug warehouse shall be classified and stored in strict accordance with the drug storage and maintenance system. The drugs shall be stored in the corresponding warehouse areas according to the drug storage conditions and requirements. The drugs shall be stacked centrally according to the batch number and validity period, and sequentially or separately according to the batch number and validity period. Stack and fill in the expiry date form every month for drugs with near-expiration dates.

5. Dispensing of drugs:

When pharmacists prepare drugs, they must rely on prescriptions issued by registered medical practitioners. Drugs are not allowed to be dispensed without a prescription from a physician. Drug dispensing work is strict. Distribution should be carried out in accordance with the requirements of four checks and ten pairs, and distribution should follow the principles of "first-in, first-out", "first-in-first-out" and distribution by batch number.

6. Adverse drug reaction monitoring:

Establish an adverse drug reaction monitoring and management team, designate full-time or part-time personnel to be responsible for adverse drug reaction reporting and monitoring, and establish and maintain adverse drug reaction monitoring files. , proactively collect adverse drug reactions and report them through the National Adverse Drug Reaction Monitoring Information Network. The content of the report should be true, complete and accurate.

7. Special drugs:

Specially managed drugs have safe storage measures that comply with regulations, and are subject to five-specialist management such as double locks for two people and consistent accounts and items. When purchasing special drugs, they should be inspected upon arrival, unpacked by two people, counted to the smallest packaging, and have special acceptance records. Returned, expired, unqualified special management drugs and waste collected in accordance with regulations should be supervised by the health department. Destruction is required, and the destruction records should comply with the requirements.

8. Problems discovered during the inspection:

Through the self-inspection team, the hospital conducted self-inspections on all aspects of drug use and quality management, from personnel organization, management system, hardware facilities, A comprehensive and detailed self-examination was conducted on management records and other aspects, and the requirements of quality management regulations for drug use were basically met. However, some shortcomings were also found. Some places involving medicines and equipment, such as medicine warehouses, pharmacies, and outpatient pharmacies, were not hygienic. The medicines are not arranged neatly, the sorting is not standardized enough, the partitions are not obvious enough, and the written records are not detailed enough. Relevant personnel in each department are ordered to conscientiously make rectifications according to the system and implement them to everyone.

9. Rectification situation:

Our hospital has rectified the following issues on the basis of self-inspection and mutual inspection:

1. Formulated an easy-to-use The system and labeling of confusing drugs are posted next to the classified drugs that are easily confused.

2. An in-service education and training system and training plan focusing on ethnic medicine have been formulated.

3. Developed a medical device purchase inspection record system.

4. A monitoring system for adverse events of medical devices has been formulated.

5. Strengthened the care and maintenance of large medical equipment. Medical device inspection, maintenance and related records have been supplemented and will be implemented for a long time.

6. Strengthen the monitoring of adverse reactions and medical device adverse events.

In actual work and implementation, there may be some subtle problems that are easily overlooked. We hope that superior leaders will provide valuable opinions on the work of our hospital. In the future work, we must continue our efforts to do a better job in our hospital’s pharmaceutical work and ensure the people’s medication safety.

3. Medical Behavior Self-Examination and Self-Correction Report Part 3

A series of medical accidents occurred in 2009, and the alarm bell for medical quality and safety sounded again. In March xx, two medical accidents occurred one after another in xx and xx counties. The first one was "fracture of right leg, surgery on left leg", and the latter one was "hernia on left side, surgery on right side". Two patients All the chief surgeons were punished for lack of responsibility. The "xxx incident" occurred in xxx hospital. When the child's condition worsened, the doctor involved was found to be playing online games. It was later determined that the relevant medical staff had serious dereliction of duty in this incident. At the beginning of XX, CCTV reported the death of xx medical professor xxx in Peking University First Hospital, pointing out that during the medical process, there were violations in the hospital where several trainee doctors worked independently.

The above incidents have once again sounded the alarm that medical accidents are more serious than tigers. Never forget the past and learn from the aftermath. These incidents are worthy of our reference and reflection. We are medical workers, angels in white. In our future work, we must have a dedicated heart and work consistently and down-to-earth. Start from now, start from yourself. I also realize that we need to pay attention to the quality of medical care. As a resident physician, I summarized based on my own situation as follows:

(1) The patient must be examined and initially treated within 30 minutes of admission.

(2) Urgent, critical, and serious patients should be treated immediately and reported to superior physicians.

(3) Complete the medical record writing within the specified time (completion within 24 hours for ordinary patients and 6 hours for critical patients; the first course of illness recording is completed on duty, and emergency patients are completed before surgery).

(4) The medical record must be written in a complete and standardized manner, with no missing items.

You must strengthen your study of medical record writing. Correction deficiencies. If your handwriting is not good, you need to practice calligraphy.

(5) Complete blood, urine, and stool tests within 24 hours, and complete liver, kidney function, and other required specialist examinations as soon as possible according to the condition.

(6) Develop a preliminary diagnosis and treatment plan based on specialist diagnosis and treatment routines.

(7) For patients under management, make rounds at least once in the morning and once in the afternoon every day.

(8) Complete the disease course record according to the prescribed time and requirements.

(9) Changes in the condition of the patients under their care should be reported to the superior physician in a timely manner.

(10) Disinfection and isolation regulations should be followed during the diagnosis and treatment process, and aseptic operations should be strictly performed to prevent the occurrence of hospital infection cases. If there are cases of nosocomial infection, please fill out the report promptly.

(11) The patient must be approved by the superior physician when being discharged from the hospital, and the discharge instructions and precautions should be noted.

(12) Strictly follow routine diagnosis and treatment operations and do not violate health regulations. We should strengthen our study of health laws in the future.

(13) Strengthen doctor-patient communication. Make your own contribution to a harmonious doctor-patient relationship.

Looking back on the medical accidents that have occurred in the past, which one did not occur due to carelessness or failure to follow routine diagnosis and treatment operations? Therefore, in actual work, we must take precautions, start with small things, and deal with unsafe factors in a timely manner to avoid medical emergencies. In fact, it is not difficult to achieve medical safety. The key lies in having a sense of responsibility. As long as everyone pays more attention, as long as they have a more serious and responsible attitude towards their work, they must do their duty at work, and they must fulfill their duties and responsibilities. No matter where they live, as long as they have a high sense of responsibility and a strong sense of mission, they will be able to avoid the occurrence of medical accidents.

4. Medical Behavior Self-examination and Self-Correction Report Part 4

In accordance with the instructions and regulations of the Municipal Food and Drug Administration, under the organization of the hospital leaders, we focused on the medical devices of the whole hospital , the equipment has been comprehensively inspected, and the specific situation is now reported as follows:

1. Strengthen management, strengthen responsibilities, and enhance quality responsibility awareness

Equip medical device quality management personnel to engage in medical device Quality management staff have professional knowledge related to medical devices, are familiar with relevant laws and regulations, can perform medical device quality management responsibilities, effectively assume the quality management responsibilities of our hospital's medical devices, guide, supervise, and inspect and correct the implementation of the quality management system. and continuous improvement, collect laws, regulations and product quality information related to the use quality of medical devices, implement dynamic management, establish files, urge relevant departments and personnel to implement medical device laws and regulations, and review medical device suppliers and the legal qualifications of medical device products, responsible for the acceptance, procurement and maintenance of medical devices, inspecting the quality of medical devices, supervising and handling of unqualified medical devices, organizing investigations and handling of medical device quality complaints and quality accidents, organizing and carrying out inspections of defective medical devices Incident monitoring and reporting, and establishing a quality management system covering the entire quality management process.

2. Self-inspection of the purchase, acceptance and storage of medical devices

In order to ensure the quality and safety of purchased medical devices and prevent the entry of substandard medical devices, our hospital The "Medical Equipment Procurement, Acceptance and Warehousing Management System", the "Large Equipment Bidding and Procurement System" and the "Medical Equipment File Management System" were established. In accordance with the provisions of the "Medical Equipment Use Quality Supervision and Management Measures", our hospital has reorganized Purchase acceptance records and medical device-related qualification files, and log on to the State Food and Drug Administration website to verify the registration certificate number of the medical device, to prevent unlicensed purchases, fake certificate purchases, purchases without certificates of conformity, and imported medical devices. There are no Chinese instructions, Chinese labels, or Chinese labels on the purchase and expired use of medical devices to ensure the safe and legal use of medical devices.

3. Self-examination of the storage conditions of the medical device warehouse

In order to ensure the quality of the medical devices stored in the warehouse, our hospital conducts inspections of the material warehouse, the inspection department warehouse and the warehouses of various departments. Check whether the storage temperature, humidity and surrounding environment meet the storage conditions of the medical devices in the warehouse. We also organize specialized personnel to do daily maintenance of medical equipment.

IV. Self-examination of Class III medical devices (focusing on implantable medical devices)

Implantable medical devices are high-risk medical devices. In order to ensure that the people use implants In order to ensure the safety and effectiveness of such devices, our hospital has specially formulated the "Implantable Medical Device Purchase Management System". Strict regulations are made on the conditions for purchased medical devices and the qualifications of suppliers. A series of qualifications submitted for implantable medical devices are strictly reviewed and inspected in accordance with relevant laws and regulations. Strengthen the information management of implantable medical devices, establish and improve the review system for the procurement, storage, storage, use, and scrap of implantable medical devices, record product information in detail, and include all information in patients' case files for management.

5. Detection and management of medical devices with suspected adverse reactions

To strengthen the management of unqualified medical devices and prevent unqualified medical devices from entering clinical practice, our hospital has specially formulated the "Medical Device Adverse Event Reporting System. If an adverse event occurs with a medical device, the location, time, adverse reactions or basic information about the adverse event should be ascertained, and records should be kept and reported to the medical device supervision and management department promptly.

6. Self-examination of the repair, maintenance and after-sales service of medical equipment

In order to keep the medical equipment in a safe state of use and meet the technical requirements and standards, our hospital has formulated the "Medical Equipment "Equipment Maintenance and Repair System", the "Medical Equipment Maintenance Record" was produced in accordance with the regulations, and the causes of equipment failure, parts that need to be replaced, and the status after repair are recorded. Our hospital also made an "Inspection Record of First Aid and Life Support Medical Equipment" for emergency medical equipment, requiring all departments to inspect emergency equipment every day to ensure that the equipment is ready for use.

7. Problems and areas for improvement during self-examination

After this period of self-examination and self-correction, the management of medical devices in our hospital has become more formalized, but There are also some problems, such as: expired and unqualified medical devices in the warehouse cannot be destroyed in time, the classification and partitioning of the warehouse are unreasonable, and there is no training and assessment for technical personnel engaged in the maintenance and repair of medical devices.

8. The focus of our hospital’s medical device work in the future

Effectively strengthen the hospital’s medical device safety work, prevent the occurrence of medical device safety incidents, and ensure the safety of medical devices for the majority of patients. In the future, we Plans:

1. Further increase the publicity of medical device safety knowledge, implement relevant systems, and improve hospitals’ awareness of medical device safety responsibilities.

2. Increase the frequency of daily inspections and supervision of medical device safety work in hospitals, promptly identify potential safety hazards of medical devices, firmly establish the awareness of "safety first", and conduct regular training for technical personnel engaged in the maintenance and repair of medical devices. Assess work and improve service levels.

3. Continue to actively cooperate with superior departments to consolidate the results achieved in the hospital’s medical device safety work, jointly create a good atmosphere for medical devices, and make greater contributions to building a harmonious society.

5. Medical Behavior Self-examination and Self-Correction Report Part 5

According to the requirements of the "Measures for the Supervision and Administration of Drugs in Medical Institutions (Trial)", our hospital's hospital drug quality management work in 20xx A self-examination was conducted, and the results of the self-inspection are now reported as follows:

1. The leadership pays attention to it and the management organization is sound.

The leaders of the hospital attach great importance to the drug management work of our hospital and have established a hospital pharmaceutical management group and a drug treatment management group, which are responsible for supervising and guiding the procurement and approval of drugs in our hospital, scientific management of drugs and rational use of drugs, The Pharmacy Department is specifically responsible for drug dispensing and drug quality management. Each position has clear job responsibilities and is conscientiously implemented.

2. Strengthen management and establish and improve the drug quality management system and pharmaceutical work system.

The hospital has established and improved the "Antibacterial Drug Hierarchical Management System", "Pharmaceutical Department Work System", "Pharmacy Formula Checking System", "Drug Procurement Management System", "Drug Maintenance Work System", "Pharmaceutical Department "Personnel Position Responsibilities" and other management systems. Through the construction of the system, the hospital has improved the management of drug quality management and pharmaceutical work.

3. Strengthen business knowledge training and learning and improve the professional quality of personnel.

The hospital organizes employees to conduct business studies every month, learn pharmaceutical regulations and pharmaceutical professional knowledge, conduct relevant assessment tests, and establish training files to further improve the employees' professional skills and knowledge.

4. Strengthen the management of drugs and pay attention to drug quality.

Strictly implement the management regulations of the superior management department on drug procurement. Our hospital purchases drugs through the Guangxi Zhuang Autonomous Region Centralized Procurement Platform for Drugs and Equipment. The drug procurement catalog is based on the "National Essential Drugs Catalog", "Urban Medical Insurance Catalog", "New Rural Cooperative Medical Care Essential Drug Catalog" and determined based on actual clinical use, and reviewed and approved by the hospital's pharmaceutical management group and pharmacotherapeutics management group, approved by the hospital leadership, and will be purchased by the Pharmacy Department in the Guangxi Zhuang Autonomous Region according to the procurement catalog The centralized procurement platform for pharmaceutical equipment purchases winning drugs at the winning bid price. Establish supplier files, strictly review the qualifications of supplier units and sales personnel, and ensure that qualified drugs are purchased from legally qualified enterprises. Our hospital strictly follows the management regulations of the superior health management department and the drug regulatory department, and purchases pharmaceutical equipment from Guangxi Jianyi Pharmaceutical, a company with drug business qualifications that won the bid. The "Business License", "Pharmaceutical Business License", "GSP Certification", the original authorization letter of the salesperson and a copy of the ID card of the pharmaceutical operating enterprise were filed, and a pharmaceutical quality assurance contract was signed. In accordance with the "Drug Administration Law" and relevant drug laws and regulations, and combined with the actual situation of our hospital, we have formulated relevant drug quality management systems: including drug purchase, acceptance, maintenance systems, prescription preparation and prescription management systems, and near-validity drug management systems , special drug management system, adverse drug reaction reporting system, etc. The purchased special management drugs are managed according to regulations and stored in special warehouses. Anti-theft and monitoring facilities are installed, and double-locked management is implemented. Special account records, and the account items are consistent. The purchased drugs have the legal tax stamp and detailed list of the supplier. The list states the common name of the drug, manufacturer, batch number, specifications, quantity, price, etc. The purchase acceptance system is implemented, and the purchased drugs are inspected by two people, and the establishment of True and complete drug acceptance records.

Drug acceptance records include the common name of the drug, manufacturer, specifications, dosage form, batch number, validity period, supplier, quantity, price, purchase date, acceptance date, acceptance conclusion, etc. The purchase and acceptance records of medicines and equipment, and the receipt records are complete, signed by both the issuer and the recipient, and are documented and available for inspection. Implement storage management of drug validity period. Drugs with validity period of less than 6 months will be warned in the management system and reported to each using department for promotion. Pharmacies and medicine depots conduct daily inspections and maintenance of drugs, report expired and damaged drugs and medical equipment once a month, handle damage reporting and approval procedures and destruction approval procedures, keep destruction records, and destroy people. , double signature of the supervisor, and 11 batches of expired drugs were reported as damaged throughout the year. Pharmacies and drug stores are equipped with air-conditioning equipment for temperature and humidity control and refrigerators to store related drugs. The drugs can be stored in accordance with storage requirements.

5. Strengthen the management of pharmacies.

Place medicines in accordance with the standardized construction requirements of pharmacies, with clear regional location signs, separate internal medicines from external medicines, and store medicines that are prone to odor transfer. Maintain the displayed medicines every day, and monitor the temperature and humidity. If the regulations are exceeded, scope, and take control measures in a timely manner. Pharmacy technicians who have been qualified in accordance with the law are responsible for the review and deployment of prescriptions. Pharmacy professional and technical personnel review prescriptions, prepare prescriptions, distribute medicines, and provide guidance on safe medication use. When dispensing prescriptions, the "four checks and ten pairs" system is strictly implemented to ensure that the medicines issued are accurate. Prescriptions are not allowed to be changed without authorization. Prescriptions that are in doubt, incompatible, or overdose should be refused to be dispensed. If necessary, they can only be dispensed after being corrected or re-signed by the prescribing physician. Both the review and dispensing personnel sign on the prescription. Relevant regulations on prescription management are strictly implemented. Prescriptions are valid on the day they are issued. The dosage of prescription drugs generally does not exceed 7 days' dosage; emergency prescriptions generally do not exceed 3 days' dosage; special prescriptions should be strictly used for special drugs, and drug prescriptions should be kept for 2 years. Health examinations are conducted every year for personnel who are in direct contact with medicines, and health records are established. The staff who are in direct contact with the drugs do not suffer from infectious diseases or other diseases that may contaminate the drugs and are in good health.

6. Earnestly implement the adverse drug reaction monitoring and reporting system.

In 20xx, our hospital *** reported 8 cases of adverse drug reactions, 1 case of adverse drug and device reactions, and 50 cases of drug abuse to the drug regulatory department.