Fan: According to the requirements of special rectification activities for medical quality and safety in medical institutions, our hospital conducted a comprehensive inspection of key departments and departments. Now the self-inspection results and rectification opinions, measures and specific rectification responsibilities are reported as follows:
Review the basic situation of medical quality and safety management in our hospital;
(1) Our hospital has a sound safety management system, with clear responsibilities and responsibility to people. Formulated the medical quality and safety management scheme and assessment standards, and improved the responsibilities of various medical management systems. In accordance with the requirements of the management plan and assessment standards, medical quality management regularly goes deep into the supervision and inspection of departments to urge the implementation of the core system. The examination results are linked to the hospital performance appraisal scheme in the form of quality scores, which effectively promotes the continuous improvement of medical quality and medical safety management.
(2) Strengthen the education of medical quality and medical safety, and the safety awareness of medical staff is constantly improved.
We conduct quality and safety education for all employees in the form of safety meetings, and sign safety responsibility letters with relevant personnel of various departments. The training and assessment of laws, regulations and rules and regulations have been strengthened. Hold? Medical quality and safety? Waiting for training. After the safety inspection, the quality control department of the hospital held a meeting to carefully study and analyze the problems and disputes found in the inspection, find out the core problems and rectification measures, and then held a meeting of section chief, head nurse and business backbone to evaluate the quality, which effectively promoted the improvement of medical quality.
Strengthen the training and assessment of "three basics" and "three strictness". According to the "three basics" training assessment plan at the beginning of the year, all departments must be assessed once every quarter, and the medical department and nursing department must hold the "three basics" assessment of the whole hospital every six months. The reference rate and qualified rate must be above 95%.
(3) Improve the plan for preventing medical disputes and accidental injuries caused by non-medical factors, and establish a mechanism for preventing and handling medical disputes.
(4) Nursing management
(1) nursing management organization
Be able to implement nursing management in strict accordance with the provisions of the Nurses' Regulations, organize head nurses and nursing staff to seriously study the Nurses' Regulations, and be knowledgeable, law-abiding and practicing according to law.
(2) Nursing human resource management
Make on-the-job training plan for nurses every year, including three basic studies, business lectures, nursing rounds, etc. Seriously carry out the plan.
(3) Clinical nursing management
Establish the concept of humanized service to ensure that patients' informed consent is implemented. The perioperative patients were visited before and after operation, and a standardized scheme was designed. All departments attach great importance to health education and have formulated the contents of health education.
(5), hospital infection management
(1) Establish and improve the hospital infection management organization.
According to the national "Hospital Infection Management Measures", our hospital has established and improved the hospital infection control team. The business dean is the director of the hospital infection management office.
(2) The responsibilities of the hospital infection control management organization have been implemented.
According to the actual situation and task requirements, our hospital formulates the hospital infection management work plan every year, so as to organize the implementation and assign responsibility to people. Hold a hospital infection management meeting once a year to summarize the recent hospital infection management work, solve the common problems found in daily work, and arrange the work focus for the next period.
(3) Strengthen the training of hospital infection management knowledge, and constantly improve the medical staff's awareness of hospital infection control and disinfection and isolation.
(4) Seriously carry out hospital infection control and disinfection and isolation monitoring, which reduced the hospital infection rate and never caused an outbreak of hospital infection. Strengthened the management of disposable articles. Strictly enforced by all departments? Measures for the administration of disposable sterile medical supplies? Disposable medical and health supplies are purchased, stored and distributed by the Equipment Department. Three certificates? Done. Each department shall collect them as required, so as to use them before use, and use them within the validity period. Disposable articles shall be collected by special personnel after use, and it is forbidden to reuse and return to the market.
Second, the existing problems:
(A) part of the medical management system has not been fully implemented.
The quality and safety awareness of individual medical staff is not high enough, and the core systems such as the responsibility system for first-visit doctors and case discussion system are sometimes not well implemented, so case discussion still needs to be handled. The evaluation system of patients' condition is not perfect, and the risk assessment of surgical patients is limited to preoperative discussion or summary, and no written risk assessment system has been established.
(2) The application of antibacterial drugs is still unreasonable.
The use of antibiotics by individual medical staff is unreasonable, and antibiotics are also used for common colds; Prophylactic medication in perioperative period is unreasonable, the application level of antibiotics is too high and the time is too long.
(3) There are still many problems in writing hospital medical records.
1, lack of analysis of the modified doctor's orders and positive test results in the course records, less analysis of the contents of rounds, and some like to keep accounts.
2. The informed consent form was not signed, and the informed consent form was not signed for self-funded medication.
Third, the rectification measures:
(a) to further strengthen the quality and safety education, improve the safety and quality awareness of medical staff.
Medical staff generally attach importance to professional knowledge and ignore the study of quality management knowledge, lack quality management knowledge and have a weak sense of quality, so that they can not consciously and actively apply quality requirements to daily medical work, and it is difficult to ensure the realization of quality objectives. Quality management is a discipline. To improve medical quality, we should not only learn medical theory and technology, but also learn the basic knowledge of quality management and constantly update the concept of quality management to meet the needs of society. Only by making medical staff establish correct quality management consciousness and master quality management methods can passive quality control be changed into active self-quality control. Therefore, it is one of the basic tasks to improve medical quality by training all medical staff on quality management knowledge and enhancing quality awareness. First of all, it is necessary to strengthen the training of medical-related laws, regulations, rules and regulations and the responsibilities of personnel at all levels. Our hospital has vigorously carried out system construction and compiled various laws, regulations, systems and responsibilities of personnel at all levels. It is necessary to seriously organize and study the Job Responsibilities of Hospital Staff, Selected Laws and Regulations Commonly Used in Hospitals, and Medical Quality and Safety Management Manual. Medical staff must master the relevant laws and regulations, core systems and personnel responsibilities, and organize the assessment of medical skills, rules and regulations and responsibilities of all staff in March of 20xx, and record the results in personal files. Strengthen the study of basic knowledge of quality management of medical staff, and improve their awareness of quality, safety and prevention.
(2) Strengthen supervision and inspection to ensure the implementation of the core system.
1, the medical department should further strengthen the quality ward round and medical record examination, which is a good measure to improve the quality of medical care, but it should pay attention to actual results and not become a mere formality. In addition to explaining the problems found in person, repeated offenders must be punished financially.
2, strengthen the three basic training and assessment, to constantly improve the assessment methods, serious assessment discipline, pay attention to the effectiveness of assessment, can not become a mere formality. Department heads should attach importance to "three basics" training and often tell medical staff the importance of "three basics" learning, which is very important to improve the technical level of medical staff.
3. Strengthen the quality management of medical records.
It is necessary to further improve the relevant systems and medical record inspection standards, and formulate reward and punishment measures to ensure the timely filing and safe circulation of hospital medical records.
4. Further strengthen the monitoring of hospital infection.
It is necessary to make further efforts in monitoring hospital infection cases, disinfection and sterilization effects, and environmental health monitoring. , strictly implement the hospital infection management system, do the work carefully, can't cope with. It is necessary to further strengthen the training and publicity of hospital infection knowledge, so that every medical staff can realize the importance of hospital infection control, consciously abide by aseptic operation technology and do a good job of personal control. Give full play to the responsibilities of the department's hospital infection control team, cooperate with the hospital feeling office to actively carry out the work, and put an end to the omission of hospital infection events.
5. Further strengthen the management of the use of antibacterial drugs.
According to the spirit of "Notice on Further Strengthening the Management of Clinical Application of Antibacterials" issued by the Ministry of Health, the specific implementation measures and reward and punishment system in our hospital were formulated, and the preventive medication during perioperative period was monitored. It is necessary to further implement the classification management system of antibacterial drugs, set prescription authority in outpatient workstations, and ensure the implementation of the system. Improve the rate of bacterial culture and drug sensitivity test, and ensure the rational use of antibacterial drugs.
(three) to further strengthen professional ethics education, and effectively improve the service level of medical personnel.
1, in accordance with the requirements of the Ministry of Health's Medical Ethics Standards and Implementation Measures for Medical Staff, conduct medical ethics education for medical staff. Make it clear to medical staff that doctors are the first to establish products? Medical ethics is the code of conduct and self-discipline of medical staff. We should establish the concept of serving the people wholeheartedly, cultivate a modest and prudent work style, and aspire to be a respected medical staff with noble medical ethics. Every doctor should memorize the contents of the Convention on Strict Self-discipline and Honest Service for Physicians and really establish it? People-oriented? 、? Patient-centered? The idea is to truly treat patients as relatives and not seek personal gain.
2. The hospital has formulated reward and punishment measures to ensure that medical staff should have a good service attitude when practicing in the hospital. Attitude determines everything, and only with the right attitude can we find the right starting point. Always remember that we are trying to cure diseases and save lives, and the interests of patients are above everything else. Never find any excuse to take an irresponsible attitude towards patients in diagnosis and treatment, such as indifference, prevarication and rudeness. No matter when, what occasion, no matter what happens, don't deal with patients in a bad mood. We should be good at self-regulation, always maintain a good mental state, and fully show our sunny side to patients.
(four) to meet the psychological needs of patients, close the relationship between doctors and patients, reduce disputes, and create a harmonious medical environment.
The patients in the hospital are psychologically complicated. They need to be cared for, respected and accepted. They need to know his diagnosis and treatment information. They need a sense of security and are eager for an early recovery. At the same time, they will also have various worries about future social problems such as family and work. All these need to be well understood, solved or satisfied by medical staff. First of all, medical staff must dress neatly, have a kind attitude and be full of energy, and introduce themselves to patients as doctors or nurses in charge, so that patients can have a good impression on medical staff, have a sense of trust and dependence, make patients feel stable and satisfied with their families, and only in the process of diagnosis and treatment can they actively cooperate and establish a positive and cooperative doctor-patient relationship. In the process of treatment, patients and their families can urgently ask medical staff to convey diagnosis and treatment information to them in time, which is also the right of patients and their families. Therefore, medical staff must communicate with them in time, solicit their opinions, and let patients and their families actively cooperate to achieve the expected goal. If you can't communicate with patients and their families frequently about their illness and treatment plan, you can't meet what they need to know, and it will also lead to misunderstandings and even medical disputes.
Fan: According to the rectification requirements of special rectification of medical quality and safety, our department conducted a comprehensive inspection of medical quality. The self-inspection results and the next rectification measures are reported as follows:
First, the existing problems:
(1) Some core medical management systems have not been fully implemented. The quality and safety awareness of individual medical staff is not high enough, and the core systems such as the responsibility system for first-visit doctors, case discussion system, shift handover and consultation are sometimes not well implemented, and case discussion still needs to be handled. The evaluation system of patients' condition is not perfect, and the risk assessment of surgical patients is limited to preoperative discussion or summary, and no written risk assessment system has been established.
(2) The application of antibacterial drugs is still unreasonable.
The use of antibiotics by individual medical staff is unreasonable, and antibiotics are also used for common colds; Prophylactic medication in perioperative period is unreasonable, the application level of antibiotics is too high and the time is too long.
(3) There are still many problems in writing hospital medical records.
1. There is a lack of analysis on the revised doctor's orders and positive test results in the course records, and there is also little analysis on the contents of rounds, and some of them are too formalized just like keeping a daily account.
2. Self-funded items such as drugs and disposable high-low value consumables with informed consent and irregular signature and without informed consent.
3. The medical record was printed, and it was not checked in time after being copied and pasted. The name does not match the hospitalization number, and the handwriting is scrawled and altered.
(d) Individual medical staff do not have a strong sense of service and sometimes do work? Cold and hard? Phenomenon, poor awareness of medical risks, weak legal awareness, insufficient communication ability between doctors and patients, and insufficient estimation of medical risks, resulting in insufficient communication between doctors and patients.
(5) The professional technical level needs to be further improved, which can not meet the needs of patients well, and the first aid skills need to be further practiced.
(six) the department management is not enough, the problem can not be regularly urged to implement the rectification, resulting in a long delay in the problem.
Second, the next corrective measures:
(a) to further strengthen the quality and safety education, improve the safety and quality awareness of medical staff.
Medical staff generally attach importance to professional knowledge and ignore the study of quality management knowledge, lack quality management knowledge and have a weak sense of quality, so that they can not consciously and actively apply quality requirements to daily medical work, and it is difficult to ensure the realization of quality objectives. Therefore, it is one of the basic tasks to improve medical quality by training all medical staff on quality management knowledge and enhancing quality awareness. First of all, we must strengthen the laws, regulations and rules related to medical care. Medical staff must master the relevant laws and regulations and the core system of medical quality, and improve their awareness of quality, safety and prevention.
(2) Further strengthen departmental management, supervision and inspection to ensure the implementation of the core system.
1, to further strengthen medical quality.
Third-level doctors should pay attention to practical results when writing medical records, and should not become a mere formality. In addition to explaining the problem in person, it should be notified once a week, and financial penalties should be imposed on repeat offenders.
2, strengthen the three basic training and assessment, at the same time to learn professional knowledge.
According to the study plan at the beginning of the year, gradually study in place and extensively carry out on-the-job training activities in this department. It is necessary to constantly improve the assessment methods, seriously assess discipline, and pay attention to the effectiveness of training.
3. Strengthen the quality management of medical records.
Carry out training on medical record writing norms, further improve relevant systems and medical record inspection standards, ensure medical record writing norms, and timely file and manage hospital medical records.
4. According to the spirit of the Notice of the Ministry of Health on Further Strengthening the Management of Clinical Application of Antibiotics, the specific implementation measures and reward and punishment system of our hospital are formulated, with emphasis on monitoring perioperative preventive drugs and prohibiting the abuse of antibiotics.
(three) to further strengthen professional ethics education, and effectively improve the service level of medical personnel.
According to the requirements of the Ministry of Health's "Medical Ethics Standards and Implementation Measures" and mass education activities, medical staff are educated in medical ethics. Cultivate a modest and prudent work style, take root in the masses, serve the front line, aspire to be a noble and respected medical worker, and truly establish? People-oriented and patient-centered? The idea is to truly treat patients as relatives and not seek personal gain.
(4) Continue to strengthen the training of doctor-patient communication skills, aiming at patients when they are admitted to hospital, when they are involved in medical treatment, when they are on the phone, when they are in surgery, when their condition changes, etc. , so as to enhance the understanding between doctors and patients, reduce the occurrence of medical disputes and ensure the signing of informed consent.