三级综合医院评审标准实施细则输血部分(国家卫生部)

三级综合医院评审标准实施细则输血部分(国家卫生部) 三级综合医院评审标准实施细则输血部分(国家卫生部) 评审标准 评审要点 4(19(1落实《中华人民共和国献血法》 、 《医疗机构临床用血管理办法(试行) 》和 《临床输血技术规范》等有关法律和规范，完善临床用血的组织管理。 【,】 1(有临床输血管理委员会，人员组成包括医疗管理、临床、输 血、麻醉、护理、检验等相关专业的专家。 2(临床输血管理委员会有明确职责，至少应包括: (1)履行对本机构临床用血的规章 制度 关于办公室下班关闭电源制度矿山事故隐患举报和奖励制度制度下载人事管理制度doc盘点制度下载 审订职责，并监督实施; (2)监测、分析临床用血情况，推进临床合理用血; (3)推广血液保护及输血新技术，对医务人员进行临床用血管理法律法 规、规章制度和临床合理用血知识教育培训。 3(有明确的职能部门(如医务处)负责临床输血管理工作。 【,】符合“,” ，并 1(输血管理委员会年度召开工作会议两次以上。记录齐全，内容充分。 2(履行对本机构临床用血的规章制度监督实施，指导临床用血，针对血 液的来源、数量、质量进行血液保障安全性评估，调查分析临床用血不 良事件及不良反应，提出干预和改进措施。 3(向公众宣传临床合理用血、无偿献血知识。 4(19(1(1 建立临床输血管理委员会并履行工作职能。 【,】符合“,” ，并 有全院输血管理定期总结分析报告，持续改进输血工作，不断提高输血 管理水平。 【,】 (有临床输血管理相关制度和实施细则。内容涵盖本机构输血管理的全 1 过程。 2(对医务人员进行临床输血相关法律、法规、规章制度培训。 【,】符合“,” ，并 1(输血科和临床医务人员对输血相关制度知晓率 100% 2(各科室按照输血管理制度的要求，开展输血管理工作，对存在问题有 改进措施并得到落实。 3(职能部门进行督导检查，对存在问题进行追踪与改进成效评价，有记 录。 4(19(1(2 依据输血管理的法律、法规和临床输血技术规范制定输血管理文件。 【,】符合“,” ，并 相关科室执行输血管理制度的要求，实际工作与制度要求符合率100%。 【,】 1(制订本医疗机构临床用血 计划 项目进度计划表范例计划下载计划下载计划下载课程教学计划下载 。 2(医疗机构建立临床用血申请分级管理制度。 3(建立临床科室和医师临床用血评价及公示制度。 【,】符合“,” ，并 1(对用血计划的实施进行考核和计划的符合性进行评价。 2(用血申请分级管理制度中指标明确，措施有 4(19(1(3 制订医院用血计划，实行用血申请分级管理，建立临床用血评价公示制度。 and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the relevant Department. (2) personal injury accident occurred, the direct punishment 0.5-10,000 yuan, responsible for the direct responsibility for the accident and the responsibility of leadership, such as concerning administrative sanctions should be dealt with by the personnel Department of the company. (3) personal injury accident occurs, the direct punishment 500-1000, who is directly responsible for the accident responsibility, give notice of criticism and 50-100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the administrative leadership of the criticism, resulting in serious consequences, the pursuit of leadership, along with 500-1000 punishment. (5) significant near miss should be attempted as the case of responsible for the accident and construction team injuries accident penalty provisions, mutatis mutandis. Eight, should perform in the construction 【,】符合“,” ，并 用血分级管理规范，用血评价纳入科室、个人的绩效考核和全面考核。 4(19(2设立输血科，具备为临床提供24 小时服务的能力，满足临床工作需要，无非法 自采、自供血液行为。 【,】 1( 根据医院的功能任务设置独立建制输血科， 与临床科室诊疗需求相称。 (输血科工作职责明确，建立相应的工作制度与岗位职责，相关技术规 2 范与操作规程。 3(由科主任与具备资质的质量控制人员组成质量与安全管理小组，负责 医疗质量和安全管理。 4(建立输血科质量管理体系。 5(科室有明确的质量与安全管理计划和目标，并组织实施。 6(参与疑难输血病例的诊断、会诊与治疗，配合临床用血事件及输血不 良反应的调查。 7(指导临床合理用血。 【,】符合“,” ，并 1(科室人员熟悉本职相关制度、岗位职责、质量与安全管理目标，熟练 掌握相关规范和规程。 2(主动征求临床对输血管理工作的意见和建议，定期对科室质量与安全 管理进行总结分析，持续改进管理工作。 4(19(2(1 有独立建制的输血科，职责明确并执行到位，开展质量与安全管理，持续改进 输血工作。 【,】符合“,” ，并 运用质量管理工具，开展质量与安全管理，持续改进质量与安全管理， 确保建立的输血质量管理体系有效运行。 【,】 1(输血科人员具备输血、检验、医疗、护理等专业知识，并接受输血相 关理论和实践技能的培训和考核。 2(输血科主任应具有高级专业技术职称资格，从事输血技术工作五年以 上，有丰富的输血相关专业知识及管理能力。 3(输血科工作人员无影响履行输血专业职责的疾病或者功能障碍。 4(输血科的房屋设置远离污染源，靠近手术室和病区，采光明亮、空气 流通，布局应符合卫生学要求，污染区与非污染区分开，至少应设置血 液入库前的血液处置室、血液标本处理室、储血室、发血室、输血相容 性检测实验室，值班室和资料保存室。 5(必备基本设备:2?,6?储血专用冰箱、-20?以下专用低温冰箱、2 ?,8?试剂冰箱、2?,8?标本冰箱、血小板保存箱、溶浆机(血浆解 冻箱) 、血型血清学离心机、标本离心机、恒温水浴箱、热合机、显微镜、 传真机、专用取血箱、计算机及输血管理信息系统等。 6(血液保存环境条件符合规定。 【,】符合“,” ，并 1(输血科实验室建筑与设施符合《,,19489-2004 实验室生物安全通 用要求》 ，业务区域与生活区域分开，业务用房面积达到相关要求。 2(人员梯队建设合理。 and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the relevant Department. (2) personal injury accident occurred, the direct punishment 0.5-10,000 yuan, responsible for the direct responsibility for the accident and the responsibility of leadership, such as concerning administrative sanctions should be dealt with by the personnel Department of the company. (3) personal injury accident occurs, the direct punishment 500-1000, who is directly responsible for the accident responsibility, give notice of criticism and 50-100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the administrative leadership of the criticism, resulting in serious consequences, the pursuit of leadership, along with 500-1000 punishment. (5) significant near miss should be attempted as the case of responsible for the accident and construction team injuries accident penalty provisions, mutatis mutandis. Eight, should perform in the construction 4(19(2(2 输血科人员结构、房屋设施和仪器设备均符合规定要求。 【,】符合“,” ，并 1(人员数量符合规定要求:输血科人员配置与床位数或与年输血量参考 比例为 1:100(床)或 1:1000 单位(以红细胞成分计算) 。 2(有输血医师，并有输血医师培养计划。 【,】 1(制订临床用血储备计划，与指定供血单位签订供血 协议 离婚协议模板下载合伙人协议 下载渠道分销协议免费下载敬业协议下载授课协议下载 。 2(有血液库存量的管理要求，能 24 小时为临床提供供血服务。 3(有应急用血的后勤(通信、人员、交通)保障能力。 4(无非法定渠道用血和自采、自供血液的行为。 【,】符合“,” ，并 根据临床用血需求制订合理的用血计划和安全储血量，有特殊用血(如 稀有血型)应急协调机制，确保急诊抢救用血。 4(19(2(3 具 备为临床提供 24 小时供血服 务的能力，满足 临床工作需要。 【,】符合“,” ，并 能与血站建立血液库存预警机制，及时掌握预警信息，协调临床用血， 临床对输血管理工作满意。 4(19(3 加强临床用血过程管理，严格掌握输血适应证，促进临床安全、有效、科学用 血。 【,】 1(为临床医护人员提供输血知识的教育与培训，每年至少一次。 2( 医院有规定将临床医师合理用血的评价结果用于个人业绩考核与用血 权限的认定。 【,】符合“,” ，并 1(各临床科室每月对医师合理用血情况进行评价。 2( 临床科室将医师合理用血的评价结果用于个人业绩考核与用血权限的 认定管理。 3(输血科每月对医师合理用血情况进行评价。 4(19(3(1 开展对临床医师输血知识的教育与培训，开展临床用血评价，促进临床合理用 血。 【,】符合“,” ，并 主管部门每季度对各临床科室及医师合理用血情况进行评价，并用于科 室质量管理评定和医师个人用血权限的认定。 【,】 1(按照相关规定，对准备输血的患者进行血型及感染筛查(肝功能、乙 肝五项、,,,、,，,、梅毒抗体)的相关检测。 2(有相关规定要求医师向患者、近亲属或委托人充分说明使用血液成分 的必要性、使用的风险和利弊及可选择的其他办法，并记录在病历中。 (1)取得患者或委托人知情同意后，签署“输血治疗知情同意书” 。 (2)同意书中须明确其他输血方式的选择权。 and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the relevant Department. (2) personal injury accident occurred, the direct punishment 0.5-10,000 yuan, responsible for the direct responsibility for the accident and the responsibility of leadership, such as concerning administrative sanctions should be dealt with by the personnel Department of the company. (3) personal injury accident occurs, the direct punishment 500-1000, who is directly responsible for the accident responsibility, give notice of criticism and 50-100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the administrative leadership of the criticism, resulting in serious consequences, the pursuit of leadership, along with 500-1000 punishment. (5) significant near miss should be attempted as the case of responsible for the accident and construction team injuries accident penalty provisions, mutatis mutandis. Eight, should perform in the construction (3)同意书中可明确同意输血次数。 (4) 《输血治疗知情同意书》入病历保存。 (5)因抢救生命垂危的患者等特殊情况需紧急输血，不能取得患者或者 其近亲属意见的，经医疗机构负责人或者授权的负责人批准后实施。 3(医院对特殊情况下的紧急输血有相关规定与批准流程。 【,】符合“,” ，并 医务人员熟悉并严格执行该规定。 4(19(3(2 执行输血前相关检测规定，输血前向患者及其 【,】符合“,” ，并 1(输血前检测率 100%。 2(输血治疗知情同意书签署率 100,。 【,】 1(医院有根据患者病情和实验室检测指标进行输血指征综合评估的指 标。 2(医院有用血后效果评价管理要求。 3(医院对输血适应证有严格管理规定，定期评价与分析用血趋势。 4(医务人员掌握输血适应证相关规定，做到安全、有效、科学用血。 【,】符合“,” ，并 1(有输血前评估指征或检测指标落实情况督导检查，有记录。 2(成分输血率 100%达至相关要求。 (19(3(3 有临床用血前评估和用血后效果评价制度，严格掌握输血适应证，做到安全有4 效、科学用血。 【,】符合“,” ，并 1(输血前评估指征或检测指标100%符合规范要求。 2(用血适应证合格率 100%均达到相关标准。 【,】 1(医院有开展自身输血、围手术期血液保护等输血技术的管理规定。 2(医院具备开展血液保护相关技术的设备条件。 3(医务人员掌握血液保护相关技术并能积极开展工作。 【,】符合“,” ，并 1(异体输血量与上年度用血量比较，其增长率低于住院患者(或手术台 数)增长率。 2(自体输血率达到 25%。 4(19(3(4 医疗机构应当积极开展血液保护相关技术，建立自身输血、围手术期血液保 护等输血技术管理制度。 【,】符合“,” ，并 1(异体输血患者人均输血量与上年度用血量相比“零”增长。 2(自体输血率达到35%。 【,】 1(医院有输血治疗病程记录的相关规范。 (1)输血治疗病程记录完整详细，至少包括输血原因，输注成分、血型 和数量，输注过程观察情况，有无输血不良反应等内容。 (2)不同输血方式的选择与记录。 (3)输血治疗后病程记录有输注效果评价的描述。 and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the relevant Department. (2) personal injury accident occurred, the direct punishment 0.5-10,000 yuan, responsible for the direct responsibility for the accident and the responsibility of leadership, such as concerning administrative sanctions should be dealt with by the personnel Department of the company. (3) personal injury accident occurs, the direct punishment 500-1000, who is directly responsible for the accident responsibility, give notice of criticism and 50-100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the administrative leadership of the criticism, resulting in serious consequences, the pursuit of leadership, along with 500-1000 punishment. (5) significant near miss should be attempted as the case of responsible for the accident and construction team injuries accident penalty provisions, mutatis mutandis. Eight, should perform in the construction (4)手术输血患者其手术记录、麻醉记录、护理记录、术后记录中出血 与输血量要完整一致;输血量与发血量一致。 【,】符合“,” ，并 有输血治疗病程记录质量的督导检查和改进措施。 4(19(3(5 输血治疗病程记录完整详细。 【,】符合“,” ，并 落实整改措施有成效，输血治疗病程记录100%符合规范要求。 4(19(4 开展血液全程管理，落实临床用血申请、申请审核制度，履行用血报批手续， 执行输血前核对制度，做好血液入库、贮存和发放管理。 【,】 1(有输血申请审核登记和用血报批登记制度。 (1)输血申请单审核率为 100%。 (2)大量用血报批审核率 100%。 (3)用血的申请单格式规范、书写规范、信息记录完整。 (4)临床单例患者用全血或红细胞超过 10,履行报批手续，需要科室 主任签名或输血科医师会诊同意，报医务科批准。 2(紧急用血必须履行补办报批手续。 【,】符合“,” ，并 职能部门和科室能按照制度和流程要求检查落实情况，定期提出总结分 析和 案例 全员育人导师制案例信息技术应用案例心得信息技术教学案例综合实践活动案例我余额宝案例 分析报告，对存在问题及时整改。 (19(4(1 落实临床用血申请、申请审核制度，履行用血报批手续。 4 【,】符合“,” ，并 职能部门和科室落实整改措施，持续改进用血审核管理有成效。 【,】 1(有输血管理信息系统。 2(有血液库存管理制度，包括血液预订、接收核对、入库、贮存、出库 及库存预警等内容。 (1)血液的出入库记录完整率为 100%。 (2)血液有效期内使用率为 100%。 (3)用血的发血单、输血记录单格式和书写规范、信息记录完整。 3(有保证血液贮存、运输符合国家有关冷链控制的标准和要求。 【,】符合“,” ，并 1(信息管理系统必须涵盖血液出入库及配发血的全过程。 2(库存预警 方案 气瓶 现场处置方案 .pdf气瓶 现场处置方案 .doc见习基地管理方案.doc关于群访事件的化解方案建筑工地扬尘治理专项方案下载 实施有效。 3(冷链控制有自动温控系统。 4(19(4(2 建立输血管理信息系统，做好血液入库、贮存和发放管理。 【,】符合“,” ，并 1(信息管理系统包括全部输血人员信息、输血管理全过程(包括血液预 订、医生申请及不良反应上报等)以及质量与安全管理等功能， 。 2(依据患者信息或血液信息追踪临床用血管理的规范性和输血不良反 应。 3(建立区域内医院间的输血信息互联共享。 【,】 1(有采集血标本的流程。 and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the relevant Department. (2) personal injury accident occurred, the direct punishment 0.5-10,000 yuan, responsible for the direct responsibility for the accident and the responsibility of leadership, such as concerning administrative sanctions should be dealt with by the personnel Department of the company. (3) personal injury accident occurs, the direct punishment 500-1000, who is directly responsible for the accident responsibility, give notice of criticism and 50-100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the administrative leadership of the criticism, resulting in serious consequences, the pursuit of leadership, along with 500-1000 punishment. (5) significant near miss should be attempted as the case of responsible for the accident and construction team injuries accident penalty provisions, mutatis mutandis. Eight, should perform in the construction 2(采集完成后必须核对标本标识与受血者是否相符。 3(输血前，按照规定的流程检查从输血科领出血液，做到准确无误。 (1)血液发出前，必须核对用于输血的血液，其标签标记的血型与受血 者的血型无误。 (2) 按规定检查领取的血液必须与输血记录单相符， 确认受血者是否正确。 (3)血液发出时必须附相容性检测的记录。 (4)血液发出前，还要检查全血和成分血是否发生溶血、是否有细菌污 染迹象，以及其他肉眼可见的任何异常现象。 4(由输血科发血者和临床科室领血者共同按规定或流程执行核对。 5(有相关流程的培训与教育，并有记录。 【,】符合“,” ，并 输血科与临床科室按照制度和流程要求检查落实情况，对存在问题及时整改。 4(19(4(3 建立输血标本采集流程，执行输血前核对制度。(?) 【,】符合“,” ，并 职能部门按照制度和流程落实监督检查， 对存在的问题与缺陷追踪评价， 有改进成效。 4(19(5 开展血液质量管理监控，制订、实施控制输血严重危害(SHOT) (输血传染疾 病、输血不良反应、输注无效)的方案，严格执行输血技术操作规范。 【,】 1(有血液贮存质量监测与信息反馈的制度。 (使用血液存放环境符合规定，有监测记录。 2 (1) 不同血型的全血、 成分血分型分层存放或在不同冰箱存放， 标识明显。 (2)储血冰箱有不间断的温度监测与记录。 (3)血液保存温度和保存期符合要求。 (4)贮血冰箱定期消毒，记录保存完整。 (5)贮血冰箱定期进行细菌监测，记录保存完整。 3(输血器械符合国家标准， “三证”齐全。 4(血袋按规定保存、销毁，有记录。 5(一次性输血耗材进行无害化处理，有记录。 【,】符合“,” ，并 科室能按照制度和流程要求，检查落实情况，对存在问题及时整改。 4(19(5(1 有血液贮存质量监测与信息反馈的制度。 (?) 【,】符合“,” ，并 职能部门按照制度和流程落实监督检查， 对存在的问题与缺陷追踪评价， 有改进成效。 【,】 1(医院有输血全过程的血液管理制度。 (1)医院有明确规定的流程，确保患者输血过程中的安全。 (2)输血前在患者的床旁由两名工作人员准确核对受血者和血液信息。 (3)明确规定从发血到输血结束的最长时限。 (4)制定使用输血器和辅助设备(如血液复温)的操作规范与流程。 (5)在血液输注过程中不得添加任何药物。 (6)输血中要监护输血过程，及时发现输血不良反应及时处理。 (7)输血全过程的信息应及时记录于病历中。 and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the relevant Department. (2) personal injury accident occurred, the direct punishment 0.5-10,000 yuan, responsible for the direct responsibility for the accident and the responsibility of leadership, such as concerning administrative sanctions should be dealt with by the personnel Department of the company. (3) personal injury accident occurs, the direct punishment 500-1000, who is directly responsible for the accident responsibility, give notice of criticism and 50-100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the administrative leadership of the criticism, resulting in serious consequences, the pursuit of leadership, along with 500-1000 punishment. (5) significant near miss should be attempted as the case of responsible for the accident and construction team injuries accident penalty provisions, mutatis mutandis. Eight, should perform in the construction 【,】符合“,” ，并 科室能按照制度和流程要求检查落实情况，对存在问题及时整改。 4(19(5(2 有临床输血过程的质量管理监控及效果评价的制度与流程。(?) 【,】符合“,” ，并 职能部门按照制度和流程落实监督检查， 对存在的问题与缺陷追踪评价， 有改进成效。 【,】 1(医院有紧急用血预案，有具体保障措施。 (1)有紧急用血的应对预案。 (2)有关键设备故障的应急措施。 2(相关人员知晓本部门、本岗位的履职要求。 【,】符合“,” ，并 输血科能按照制度和流程要求检查落实情况，并有持续改进措施。 4(19(5(3 医院有应急用血预案，并能得到落实。 【,】符合“,” ，并 紧急用血的执行情况 (重点夜间、 节假日) ， 与医院规定的要求保持一致。 4(19(5(4 有控制输血严重危害(SHOT)的方案与实施情况记录。 (?) 【,】 1(有控制输血严重危害(SHOT)的预案，记录及时、规范。 (1)监测输血的医务人员经培训，能识别潜在的输血不良反应症状。 (2)有确定识别输血不良反应的标准和应急措施。 (3)发生疑似输血反应时医务人员有章可循，并应立即向输血科和患者 的主管医师报告。 (4)一旦出现可能为速发型输血反应症状时(不包括风疹和循环超负 荷) ，立即停止输血，并调查其原因。要有调查时临床及时处理患者的规 范。 (5)输血科应根据既定流程调查发生不良反应的原因，确定是否发生了 溶血性输血反应。立即查证: 1)患者和血袋标签确认输给患者的血是与患者进行过交叉配血的血。 2)查看床旁和实验室所有记录，是否可能将患者或血源弄错。 3)肉眼观察受血者发生输血反应后的血清或血浆是否溶血。如果可能， 该标本应和受血者输血前的标本进行比较。 4)用受血者发生输血反应后的标本做直接抗人球蛋白试验。 (6)实验室应制定加做其他相关试验的要求，以及做相关试验的标准。 (7) 输血科主任负责解释上述试验结果并永久记录到受血者的临床病历 中。 (8)当输血反应调查结果显示存在血液成分管理不当等系统问题时，输 血科主任应积极参与解决。 (9)输血后献血员和受血者标本应依法至少保存 7 天，以便出现输血反 应时重新进行测试。 (10)职能部门会同输血科对输血不良反应评价结果的反馈率为100%。 2(相关部门应根据既定流程调查发生不良反应，有记录。 3( 相关部门对相关人员进行确定识别输血不良反应的标准和应急措施的 再培训与教育。 and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the relevant Department. (2) personal injury accident occurred, the direct punishment 0.5-10,000 yuan, responsible for the direct responsibility for the accident and the responsibility of leadership, such as concerning administrative sanctions should be dealt with by the personnel Department of the company. (3) personal injury accident occurs, the direct punishment 500-1000, who is directly responsible for the accident responsibility, give notice of criticism and 50-100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the administrative leadership of the criticism, resulting in serious consequences, the pursuit of leadership, along with 500-1000 punishment. (5) significant near miss should be attempted as the case of responsible for the accident and construction team injuries accident penalty provisions, mutatis mutandis. Eight, should perform in the construction 【,】符合“,” ，并 1(科室能按照制度和流程要求检查落实情况，对存在问题及时整改。 2(有职能部门对相关人员进行培训与教育后考核的记录。 3(有血液输注无效的管理措施。 4(有输血传染性疾病的管理措施和上报制度 【,】符合“,” ，并 1(相关医务人员熟悉输血严重危害(SHOT)方案、处置规范与流程， 知晓率 100%。 2(职能部门按照制度和流程落实监督检查，对存在的问题与缺陷追踪评 价，有改进成效。 4(19(6 落实输血相容性检测的管理制度，做好相容性检测实验质量管理，确保输血安 全。 【,】 1(有输血前的检测管理制度。 (1)凡遇有输血史、妊娠史或短期内需要接受多次输血的患者，应开展 不规则抗体筛检。 2)按照要求规范开展输血前检验项目:,,,正反定型、,,,、交 ( 叉配血、输血感染性疾病免疫标志物等指标。 (3)交叉配血必须采用能检查不完全抗体的实验方法。 4)血液发出后，受血者和供血者标本于 2(?,6?保存至少 7 天。 (输血相容性检测报告内容完整性 100,。 2 3(输血相容性检测的项目组合既能保证临床用血安全又不过度检测。 4(用于输血相容性检测的试剂应符合相应标准。 5(用于输血相容性检测的仪器设备符合相应要求。 【,】符合“,” ，并 科室能按照制度和流程要求检查落实情况，对存在问题及时整改。 4(19(6(1 有输血相容性检实验室的管理制度。 【,】符合“,” ，并 职能部门按照制度和流程落实监督检查， 对存在的问题与缺陷追踪评价， 有改进成效。 【,】 1(建立和实施与检测项目相适应的室内质量控制流程，应包括: (1)质控品的技术规则定义。 (2)质控品常规使用前的确认。 (3)实施质控的频次。 (4)质控品检测数据的适当分析方法。 (5)质控规则的选定。 (6)试验有效性判断的标准。 (7)失控的判定标准、调查分析、处理和记录。 【,】符合“,” ，并 1( 参加国家级或省级室间质量评价机构组织的输血前相关血液检测室间 质量评价，成绩合格。 2(参加室间质量评价应当按常规检测方法与常规检测标本同时进行，不 得另选检测系统，保证检测结果的真实性。 and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the relevant Department. (2) personal injury accident occurred, the direct punishment 0.5-10,000 yuan, responsible for the direct responsibility for the accident and the responsibility of leadership, such as concerning administrative sanctions should be dealt with by the personnel Department of the company. (3) personal injury accident occurs, the direct punishment 500-1000, who is directly responsible for the accident responsibility, give notice of criticism and 50-100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the administrative leadership of the criticism, resulting in serious consequences, the pursuit of leadership, along with 500-1000 punishment. (5) significant near miss should be attempted as the case of responsible for the accident and construction team injuries accident penalty provisions, mutatis mutandis. Eight, should perform in the construction 3(输血科对于室内失控项目和室间质量评价不合格的项目，及时查找原 因，采取纠正措施。 4(19(6(2 做好相容性检测质量管理，开展室内质量控制，参加输血相容性检测室间质评。 【,】符合“,” ，并 近三年室间质量评价结果全部合格。 【,】 1(有紧急抢救配合性输血管理制度。 2(有紧急抢救非同型输注和管理流程。 3(明确启动紧急抢救配合性输注的批准机构及执行部门的职责。 【,】符合“,” ，并 有紧急抢救配合性输血管理制度的培训和记录 4(19(6(3 建立紧急抢救配合性输血管理制度。 【,】符合“,” ，并 职能部门按照制度和流程落实监督检查， 对存在的问题与缺陷追踪评价， 有改进成效。 and pump installation engineering construction and acceptance specification for lifting 6 HG20201-2000 construction installation engineering construction standard 7, HG ... Pressure gauges, using an installed spark arrestor for acetylene cylinders, illegal carrying, using gas cylinders, each operator fined 20 Yuan. Gas bottle without the hot sun exposure measures, responsibilities of team a fine of 50 Yuan. (7) at height and the opening and provisional protective measures have been taken, the responsible unit fined 200 Yuan, construction person in charge a fine of 50 Yuan. (8) no permit to work and the job in accordance with the provisions, on the job unit fined 300 yuan, the unit will charge a fine of 100 Yuan. 7.5.3 accident penalties (1) injuries fatalities directly punished 1~2 million. Direct responsibility for the accident and have the corresponding responsibility of leadership, such as concerning administrative sanctions, should be brought to the company or the relevant Department. (2) personal injury accident occurred, the direct punishment 0.5-10,000 yuan, responsible for the direct responsibility for the accident and the responsibility of leadership, such as concerning administrative sanctions should be dealt with by the personnel Department of the company. (3) personal injury accident occurs, the direct punishment 500-1000, who is directly responsible for the accident responsibility, give notice of criticism and 50-100 economic sanctions against them. (4) to conceal the accident, reported without undue delay or false, to inform the administrative leadership of the criticism, resulting in serious consequences, the pursuit of leadership, along with 500-1000 punishment. (5) significant near miss should be attempted as the case of responsible for the accident and construction team injuries accident penalty provisions, mutatis mutandis. Eight, should perform in the construction