药品管理质量考核标准

药品管理质量考核标准,,,

序号,检查内容,存在问题,分值

1,记录卡（本）管理1.0,1.1药品的数量与药品登记卡数量不符,0.2

,,1.2精神类药品未加锁存放，用后无登记,0.2

,,1.3常备药品用后未及时补充,0.2

,,1.4抢救药品无交接记录,0.2

,,1.5麻醉药柜内的基数卡未及时清点及签字,0.2

2,常备药1.0,2.1品种未固定,0.1

,,2.2基数未固定,0.1

,,2.3药卡与药品名称不符,0.1

,,2.4药卡与药品数量不符,0.1

,,2.5无责任者标识,0.05

,,2.6无每日交接班记录,0.1

,,2.7批号变化未随时登记,0.1

,,2.8用后未及时补充,0.1

,,2.9近期未先使用,0.05

,,2.10存放过期药品,0.1

,,2.11距失效期三个月的药品未执行预警机制,0.1

3,抢救药1.0,3.1无专人管理,0.25

,,3.2无交班记录,0.25

,,3.3无护士长每周检查记录,0.25

,,3.4其余同常备药,0.25

4,麻醉药品、I类精神药品1.0,4.1未加锁存放,0.4

,,4.2标识不醒目,0.4

,,4.3未专柜存放,0.4

,,4.4无专人保管,0.4

,,4.5钥匙未随身携带,0.4

,,4.6无基数药卡,0.5

,,4.7无每班交接班记录,0.4

,,4.8交接班未清点,0.4

,,4.9交接班未签字,0.4

,,4.10未建立特殊药品使用登记本,0.5

,,4.11登记本未注明患者姓名,0.5

,,4.12登记本未注明患者床号,0.5

,,4.13登记本未注明使用药品名称,0.5

,,4.14登记本未注明使用药品剂量,0.5

,,4.15登记本未注明使用药品日期,0.5

,,4.16登记本未注明使用药品时间,0.5

序号,检查内容,存在问题,分值

4,麻醉药品、I类精神药品1.0,4.17护士未签全名,0.04

,,4.18用后未保留空瓶,0.04

,,4.19有弃去量未注明,0.04

,,4.20有弃去量未双人签字,0.04

,,4.21提供住院患者以外人员使用,0.04

,,4.22未按医嘱使用,0.04

,,4.23私自取用外借,0.04

5,高危药品1.0,5.1未单独存放,0.25

,,5.2标识不醒目,0.25

,,5.3使用时未双人核对,0.25

,,5.4同常备药,0.25

6,Ⅱ类精神药品1.0,6.1未单柜保管,0.5

,,6.2无交接记录,0.5

7,贵重药品1.0,7.1无数目登记,0.15

,,7.2未说明床号,0.15

,,7.3未说明姓名,0.15

,,7.4未加锁管理,0.15

,,7.5使用后未保留空瓶,0.2

,,7.6护士长未检查空瓶,0.2

8,药品贮存1.0,8.1须低温贮存的药品未存放于冰箱保鲜层（胰岛素注射剂、抗生素注射剂、疫苗、血制品等）,0.15

,,8.2未按品种摆放,0.1

,,8.3不整洁,0.1

,,8.4摆放无序,0.1

,,8.5未分类放置（注射剂、内服药、外用药应严格分开）,0.1

,,8.6药品冰箱有非药品存放,0.15

,,8.7避光药未避光保存（维生素C、氨茶碱、硝普钠注射剂、肾上腺素注射剂等）,0.15

,,8.8存放裸药，处方药柜不按患者摆放，剩余药品未及时退掉,0.15

9,专人管理1.0,9.1未定期检查药品质量,0.15

,,9.2未定期检查药品批号,0.15

,,9.3未定期检查药品生产日期,0.15

,,9.4未定期检查药品失效期,0.15

,,9.5未定期检查药品数量,0.15

,,9.6未做好登记、未签字盖章,0.15

,,9.7未分类存放,0.1

序号,检查内容,存在问题,分值

10,处方药柜1.0,10.1未按患者摆放，有散药,0.2

,,10.2剩余药品未及时退掉,