Self-inspection report of medical institutions

202 1 self-inspection report of medical institutions (6 articles in total)

How time flies! The work is over. In the course of our work, we have seen good aspects and areas that need improvement. At this time, it is very necessary to write a self-inspection report. You can refer to the model essay before writing. The following is the 202 1 self-examination report of medical institutions (generally 6 articles) I compiled for you, hoping to help you.

Self-inspection Report of Medical Institutions 1 Huaxi District Health and US Food and Drug Administration:

In order to further strengthen the supervision of medical and health institutions in my township, it is of great significance to adhere to the basic principles of deepening the reform of medical and health system, improving medical quality, ensuring medical safety, improving the utilization rate of grassroots medical services and improving the health status of the people. My township seriously organized personnel to conduct self-examination on township hospitals and three village clinics; The self-inspection report is as follows:

First, the supervision and licensing of medical personnel's professional qualifications

Medical staff in our township strictly abide by relevant laws, regulations, rules and industry requirements. Medical staff and outpatient doctors in health centers must obtain the qualifications of practicing doctors or assistant doctors, and nurses have nursing qualifications. Those who have not obtained the qualification certificate shall not engage in the diagnosis and treatment of medical posts. Rural doctors can only carry out medical business if they have obtained the qualifications of rural doctors or rural doctors. Strictly follow the Law on Medical Practitioners, Regulations on the Management of Rural Doctors and Regulations on Nurses. Non-health technicians are strictly prohibited from engaging in diagnosis and treatment activities. In strict accordance with the "Regulations on the Administration of Medical Institutions" and other relevant laws and regulations, carry out the diagnosis and treatment business that is suitable for its functions and tasks, and strictly practice the scope; No violations of laws and regulations were found in the self-examination.

Two, establish and improve the rules and regulations, standardize medical service behavior.

In accordance with the requirements of laws, regulations, rules, norms and technical specifications such as Regulations on the Administration of Medical Institutions, Regulations on the Administration of Rural Doctors, Measures for the Administration of Township Hospitals, and Measures for the Administration of Hospital Infection, my township has established, improved and checked the implementation of various management rules and regulations; Strengthen the management and control of medical quality, standardize the writing and storage of medical documents, and rationally use drugs and medical devices to ensure medical safety; Strictly implement hospital infection prevention and control measures and strengthen the management of disposable medical equipment and consumables; The treatment of medical wastes and the harmless treatment of sewage and dirt shall be carried out in accordance with the Regulations on the Administration of Medical Wastes. After strict self-examination, there are no illegal personnel and incidents in my hometown.

Third, the existing problems

1. In the future, it is necessary to further strengthen the training of primary medical personnel, carry out education on medical quality and safety, medical ethics, and organize relevant training on laws and regulations, rational drug use, hospital infection, diagnosis and treatment skills, and doctor-patient communication.

2 to carry out publicity and education on medical knowledge of the masses, guide the masses to correctly understand medical risks, and improve medical safety awareness.

After strict self-examination, this is generally the case in my hometown. I hope that the superior leaders will guide and improve more in the future.

4. Gradually improve, strive to deepen medical and health reform, and improve the quality of medical services.

Self-examination report of medical institutions 2 In order to further strengthen the legal practice of radiation diagnosis and treatment in our county, according to the requirements of the Municipal Health Bureau on "self-examination of the legal practice of radiation diagnosis and treatment", our hospital conducted a self-examination of the legal practice of units carrying out radiation diagnosis and treatment activities in our county from May 13 to May 17. The inspection situation is summarized as follows:

I. Basic information

There are 12 institutions engaged in radiation diagnosis and treatment within the jurisdiction of our county (2 Chinese medicine hospitals and township mines hospitals, 7 township hospitals, maternal and child health care centers, CDC and Kangbao plasmapheresis stations), 25 radiation diagnosis and treatment equipment and 16 radiation workers. All 12 units that carry out the practice of radiation diagnosis and treatment according to law have valid radiation diagnosis and treatment licenses, and all radiation workers have participated in the training related to radiation diagnosis and treatment protection organized by the higher health department, with the training rate of100%; Occupational health monitoring rate is 88%; The personal dose monitoring rate is100%; In 20xx, the total number of X-ray diagnoses in the county was 16623.

Second, the main problems

1. Although all radiation diagnosis and treatment units are equipped with corresponding protective equipment for radiation workers, there is a relative lack of protective equipment for patients.

2. Some radiation diagnosis and treatment institutions did not carry out condition testing on radiation diagnosis and treatment equipment.

III. Future Work Plan

1, strengthen the supervision of the work quality and safety protection of all radiation diagnosis and treatment units in the county, urge them to equip radiation workers and patients with necessary protective equipment, and actively organize radiation workers to participate in radiation health protection training organized by higher health administrative departments.

2, the radiological diagnosis and treatment institutions of radiological diagnosis and treatment equipment status detection and "radiation diagnosis and treatment license" for verification, the radiological diagnosis and treatment equipment at least once a year to check, to detect unqualified units of the "radiation diagnosis and treatment license" annual inspection will not be accepted.

3. Combine the occupational health monitoring and personal dose monitoring of radiation workers in various radiation diagnosis and treatment units with the annual assessment, and actively urge them to carry out occupational health monitoring and personal dose monitoring of radiation workers.

3. Self-inspection report of medical institutions of the Municipal Health Bureau:

In order to further strengthen the supervision of medical and health institutions in my township, adhere to the basic principles of deepening the reform of medical and health system, improve medical quality, ensure medical safety, improve the utilization rate of primary medical services, and improve the health status of the people, it is of great significance. My township has carefully organized personnel to conduct self-examination and self-evaluation of medical institutions in the township. Self-examination and self-assessment are as follows:

I. Personnel qualification supervision

There are 24 rural medical staff in the jurisdiction, including 0/5 in health centers and 9 in four village clinics. There are medical practitioners 1 person in the health center, 3 assistant medical practitioners, practical nurse 1 person, B-ultrasound and electrocardiograph 1 person, 2 assistant medical practitioners in the village clinic and 2 in the village. All the above personnel have been registered in our jurisdiction and filed with the Municipal Health Bureau. Practitioners carry out practice activities in accordance with the Law on Medical Practitioners, Regulations on the Management of Rural Doctors, Regulations on Nurses and other laws and regulations, so as to prevent people without professional qualifications from engaging in relevant medical and nursing work.

Two. The implementation of various rules and regulations

In accordance with the requirements of laws, regulations, rules, norms and technical specifications such as Regulations on the Administration of Medical Institutions, Regulations on the Administration of Rural Doctors, Measures for the Administration of Township Hospitals and Measures for the Administration of Hospital Infection, establish and improve various management rules and regulations and check the implementation; Strengthen the management and control of medical quality, standardize the writing and storage of medical documents, and rationally use drugs and medical devices to ensure medical safety; Strictly implement the prevention and control measures of hospital infection and strengthen the management of disposable medical devices and immersion medical devices; The treatment of medical wastes and the harmless treatment of sewage and dirt shall be carried out in accordance with the Regulations on Physical Management of Medical Wastes. And strict self-examination.

Three. Standardize medical service behavior

1. Strengthen the management and preservation of medical care documents for reference.

2. Rational use of essential drugs

(1) All rural medical institutions in our jurisdiction have used the essential drugs prescribed by the state.

(2) In strict accordance with the Measures for the Administration of Clinical Application of Antibacterials, the leading group for the administration of antibacterial drugs in hospitals dynamically manages antibacterial drugs and prescriptions in medical institutions under their jurisdiction, and timely intervenes in irrational drug use.

(3) Various charges

We strictly follow the national price policy on the Regulations on the Management of Medical Service Charges, and implement a full disclosure system for all charges. Clearly marked. Convenience supervision.

(4) Prevention and control of key infectious diseases

Actively carry out work in accordance with the Law on the Prevention and Control of Infectious Diseases and the Regulations on the Management of Infectious Diseases, make unified arrangements, assign responsibilities to people, adhere to the responsibility system of first diagnosis, actively refer patients or suspected cases of infectious diseases, report the epidemic situation, and actively cooperate with the prevention and control departments at higher levels to carry out relevant epidemiological work. Do not shirk or intercept infectious patients. existing problems

1. In the future, it is necessary to further strengthen the training of primary medical personnel, carry out education on medical quality, medical safety and medical ethics, earnestly study various laws and regulations, and carry out training in business skills and doctor-patient communication.

2, to carry out publicity and education of medical knowledge, guide the masses to correctly understand the medical risks, improve the medical safety awareness of the masses and the ability to identify counterfeit and shoddy drugs.

3. Implement the accountability system.

Those who fail to operate according to the operating rules at work and have medical accidents or medical disputes will be dealt with seriously in accordance with relevant laws and regulations and will not be tolerated.

Self-inspection report of medical institutions. After the Provincial Bureau issued the Work Plan for Special Inspection of Chinese Herbal Pieces in Hubei Province, in order to further standardize the production and operation of Chinese Herbal Pieces in our city and ensure that the production and operation of Chinese Herbal Pieces are strictly in accordance with the Notice on Strengthening the Supervision and Management of Chinese Herbal Pieces (US Food and Drug Administration [20xx] No.25), the provincial bureau earnestly implemented the requirements for special rectification of drug safety in 20xx and the work plan for drug production and operation, and combined with the actual daily supervision of Chinese Herbal Pieces production, our bureau carried out.

I. Basic information

There are two Chinese herbal pieces production enterprises in our city, namely Hubei Shengdetang Pharmaceutical Co., Ltd. and Hubei Yisheng Pharmaceutical Co., Ltd., in addition to Hanchuan Calomel Factory (production scope: mercuric preparation calomel and red powder), Hubei Junhui Pharmaceutical Co., Ltd. (production scope: L-borneol) and Hubei Nuokete Pharmaceutical Co., Ltd. (production scope: Chinese medicine extraction).

Hubei Yisheng Pharmaceutical Co., Ltd. and Hanchuan Calomel Factory are preparing for GMP certification because of their relocation in different places. The enterprise declared to submit GMP certification application before the end of this year. Hubei Nockert Pharmaceutical Co., Ltd., Hubei Shengdetang Pharmaceutical Co., Ltd. and Hubei Junhui Pharmaceutical Co., Ltd. passed GMP certification.

Second, the work situation

1, strengthen leadership and make inspection plan.

In order to ensure the effectiveness of the special inspection of Chinese herbal pieces, our bureau, based on the actual situation in Xiaogan, formulated the Work Plan for the Special Inspection of Chinese herbal pieces in Xiaogan City, which was distributed to the bureaus of counties (cities, districts) and related enterprises, safety supervision departments and market supervision departments to be responsible for the special inspection of the production and circulation of Chinese herbal pieces respectively, so as to further raise awareness, unify thinking and clarify the responsibilities of various functional departments and relevant responsible persons.

2, formulate measures to strengthen supervision and inspection.

Through this special inspection, we will further implement the drug safety responsibility system of "local governments take overall responsibility, management departments take their respective responsibilities, and enterprises are the first responsible persons"; Strictly implement the quality management norms of drug production and operation, strictly control the quality, and realize the traceability of quality; Further promote the construction of standardized pharmacies in medical institutions and effectively improve the management level of the use of Chinese herbal pieces; Severely crack down on the illegal production, sale and use of Chinese herbal pieces to ensure the quality and safety of Chinese herbal pieces.

Third, check the situation.

Hubei Shengdetang Pharmaceutical Co., Ltd. holds the Pharmaceutical Production License and the Pharmaceutical GMP Certificate; Hubei Yisheng Pharmaceutical Co., Ltd. holds GMP certification of pharmaceutical production license.

Hubei Shengdetang Pharmaceutical Co., Ltd. takes Chinese herbal medicines as starting materials, and produces 102 standard Chinese herbal pieces in 20xx. The Chinese herbal medicines used for production basically meet the medical standards, and the origin of Chinese herbal medicines is relatively fixed (Dawu County real estate Chinese herbal medicines); Can strictly implement the national drug standards and local Chinese herbal pieces processing norms and technological procedures; Basically organize production under GMP conditions; The produced Chinese herbal pieces leave the factory after passing the inspection, and a paper inspection report is attached with the goods; Do not outsource semi-finished or finished Chinese herbal pieces for sub-packaging or change the packaging label; The entrusted inspection items have been filed as required.

Four. Some problems were also found in the problem check.

1, a few enterprises and employees are not aware of organizing production management under GMP conditions;

2. GMP management system is not strict enough in the production of Chinese herbal pieces; 3. A few enterprises did not strictly control the quality of Chinese herbal medicines; I'm not familiar with the processing norms and technological processes of local Chinese herbal pieces. For the above problems found in the inspection, our bureau will further strengthen publicity and supervision, and order relevant enterprises to make rectification within a time limit to ensure that the special inspection of Chinese herbal pieces is implemented and achieved remarkable results.

Self-inspection report of medical institutions 5 In order to improve the quality of medical services and the level of technical services, our service station has carried out strict self-inspection and self-correction according to the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions. The relevant self-inspection situation is reported as follows:

First, leaders attach importance to it and are well organized.

Our service station held a meeting and made strict arrangements for self-inspection. At the meeting, a self-examination leading group was set up to carry out self-examination and self-correction in strict accordance with the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions, and achieved remarkable results.

Second, the basic situation of self-examination

(1) Institutional self-examination: The full name of the unit is "Fengyuan Community Health Service Station in Keyuan Street", which is a private non-enterprise located in; Legal representative: person in charge: Medical Institution Practice License issued by District Health Bureau, with the practice license number of 20xx65438+February 23rd. Our service station has strictly managed the practice license of medical institutions and has never altered, bought, sold, transferred or rented it. 6 beds, including preventive health care and general medical treatment; The business building area is 320 square meters.

(2) Personnel self-examination: attending physician 1 person, practicing physician 1 person, 2 assistant physicians and 3 nurses in our service station. Our service station has never been registered to carry out practical activities on a large scale; Persons who have not obtained the qualifications of practicing doctors or nurses or doctors registered with one license and many places shall not be used to engage in medical activities. All medical staff are listed for posts, and a supervision column is set up in the hall to make it public.

(3) Improve service quality: strengthen medical quality management and implement medical quality assurance scheme according to relevant regulations and standards of health administrative departments; Regularly check and assess the implementation of various rules and regulations and post responsibility system for personnel at all levels, ensure medical safety and service quality, and continuously improve service level.

(4) Cross-infection management in hospitals: A leading group for cross-infection management in service stations was established, with members including. Relevant personnel often receive education and training, and establish and improve relevant rules and regulations such as medical waste treatment management, nosocomial infection and disinfection management, and waste leakage treatment plan. The source, type and quantity of medical waste shall be completely recorded by special personnel, and the disinfection effect shall be regularly monitored by key departments and parts. The label of the prepared disinfectant is clear, complete and standardized.

(V) Disposal of solid medical wastes: all medical wastes are collected by classification, the temporary storage time of wastes is marked with warning signs according to regulations, the waste containers are sealed and fastened, and the temporary storage places of wastes are "five-proof", and the transportation and transfer of medical wastes are handled by special personnel with signature records.

(6) Disposal of disposable medical supplies: All disposable medical supplies are collected by the medical waste treatment station after soaking, disinfection and destruction.

(VII) Epidemic Management Report: Our service station has established a strict epidemic management and reporting system, and designated a special person to be responsible for epidemic management. The contents of the epidemic situation register are complete, and the epidemic situation report card is standardized. The epidemic situation report is checked once a month, without omission or delay.

(8) Self-inspection of drug management: After investigation, our service station has never used counterfeit drugs, expired, invalid or illegal drugs. Strictly implement the provisions of the antibacterial drug system.

Third, there are shortcomings.

First, due to lack of funds, some medical equipment can not be maintained or updated in time, which affects the in-depth development of related businesses to a certain extent and has insufficient development potential; Second, limited by the establishment, the staff is tight, the workload is heavy, there are not many opportunities for further study in provincial medical institutions, and the knowledge updating cycle is long, which has affected the service level to a higher level to some extent.

Fourth, the direction of future efforts.

Our service station must take this self-examination as an opportunity, under the leadership of the superior business department, conscientiously implement the spirit of the superior meeting, strictly abide by the Regulations on the Management of Medical Institutions, strengthen management measures, optimize the quality of personnel, be pragmatic, pioneering and innovative, and constantly improve the quality of medical services and technical services.

Self-inspection report of medical institutions 6 is to implement the quality inspection of drugs and medical devices in our hospital by the county food and drug administration, ensure the safe and effective use of medical devices by the people, and standardize the use and management of drugs. The hospital set up a self-inspection team headed by the dean in charge, and conducted self-inspection one by one according to the Drug Administration Law, the Quality Management Standard for Drug Use and the Standard for Regulating Pharmacy Work. The self-inspection team has done a lot of detailed self-inspection work, and the self-inspection report is as follows:

I. Institutions, personnel and systems:

Our hospital has legal qualifications such as practicing license of medical institutions. A drug quality management organization was established, which was composed of the director, the head of pharmacy department, the head of pharmacy, the head of quality and the buyer, and defined the responsibilities of personnel and organizations at all levels. At the same time, various quality management systems have been formulated, continuing education and training plans have been established, and the quality of personnel has been improved. Conduct annual health check-ups for those who have direct contact with drugs in pharmaceutical work, and establish health files to ensure the safety and effectiveness of drug use.

Second, the procurement and acceptance:

Purchased drugs in strict accordance with the centralized drug procurement system formulated by the Health Bureau. Purchasing drugs from enterprises with pharmaceutical production and business qualifications; The acceptance of drugs in storage shall be carried out in strict accordance with the standard operating procedures, and the quality of drugs purchased and returned after sale shall be accepted batch by batch in strict accordance with the statutory quality standards and contract quality terms.

Three, the implementation of standardized pharmacy management system:

In strict accordance with the standard of standardized pharmacy, the hospital pharmacy, pharmacy library and outpatient pharmacy are managed.

Four, drug storage and maintenance:

The warehouse is divided into drug warehouse and medical device warehouse, and each warehouse is divided into qualified area, pending inspection area, unqualified area and return area. Each area is managed according to the regulations, that is, the qualified area is green, the returned area to be inspected is yellow, and the unqualified area is red. After acceptance, the drugs should be stored in a special warehouse and classified in strict accordance with the Drug Storage and Preservation System, and stored in the corresponding reservoir area according to the storage conditions and requirements of drugs. Drugs and non-drugs, drugs for internal use and external use, prescription drugs and over-the-counter drugs should be stored separately, and drugs and odorous dangerous goods should be stored separately from other drugs. Drugs should be piled up in a centralized way according to the batch number and expiration date, or piled up separately according to the order of batch number and expiration date. For drugs approaching the expiration date, an expiration date table should be filled out every month.

Five, the deployment of drugs:

Pharmacists must prepare drugs with prescriptions issued by registered medical practitioners, and drugs may not be prepared without prescriptions issued by doctors. Drug preparation should be carried out in strict accordance with the requirements of four checks and ten pairs, and distribution should follow the principles of "production first, distribution first", "distribution first in the near future" and distribution according to batch number.

Six, adverse reaction monitoring:

Establish an adverse drug reaction monitoring and management team, designate full-time or part-time personnel to be responsible for reporting and monitoring adverse drug reactions, establish and save adverse drug reaction monitoring files, actively collect adverse drug reactions, and report them through the national adverse drug reaction monitoring information network. The contents of the report shall be true, complete and accurate.

Seven, special drugs:

Special management drugs have safe storage measures that meet the requirements, and five special management methods are implemented, such as double locks for two people and matching accounts and goods. The purchased special drugs shall be accepted upon arrival, unpacked by two persons, counted according to the minimum package, and special acceptance records shall be kept. The returned, expired and unqualified specially managed drugs and wastes recovered according to regulations shall be destroyed under the supervision of the health department, and the destruction records shall meet the requirements.

Eight, problems found in the inspection:

Through the self-inspection team, all aspects of hospital drug use and quality management were self-inspected, including personnel organization, management system, hardware facilities, management records, etc., which basically met the requirements of drug use quality management norms. However, we also found some shortcomings, such as poor sanitary conditions, irregular drug placement, irregular classification, unclear zoning, and insufficient written records in some places involving medical equipment. All stations, groups and departments shall be ordered to make serious rectification according to the system and implement it to people.

In actual work and implementation, there may be some subtle problems that are easily overlooked. I hope the superior leaders will put forward valuable opinions on our work. In the future work, we will make persistent efforts to do a better job in pharmaceutical affairs in our hospital and ensure the safety of people's medication.