Rectification report
On 20 1 year 1 month, the inspection team of county health bureau inspected our station. In view of the problems existing in the inspection, the community neighborhood Committee and relevant responsible persons held a meeting and set up a rectification team. Under the guidance of the County Health Bureau, the County Health Supervision Institute and the Central Health Center, the following policies and regulations have been formulated according to the Detailed Rules for the Implementation of the Regulations on the Administration of Medical Institutions and the Regulations on the Administration of Medical Institutions: "On further strengthening the management of medical safety and quality and preventing medical errors and accidents, the rectification situation is now reported as follows:
First, standardize personnel management and improve the files of professional and technical personnel.
According to the requirements of the Administrative Measures for Medical Practitioners, Nurses Regulations and other laws and regulations, medical, nursing, pharmacy and technical personnel must be registered with certificates, and nurses who have not obtained the qualification to practice at present work under the leadership of the person in charge of the corresponding department designated by the service station. At the same time, establish personnel files and copy the relevant academic qualifications and qualification certificates of on-the-job personnel for future reference.
Two, strengthen internal management, establish and improve management rules and regulations.
1, establish and improve the medical quality monitoring system.
A, established a complete medical management organization, and improved the service quality and service level of the hospital.
Completely meet the clinical needs.
B, head of each department in-depth clinical line, at any time to the hidden dangers in medical quality and not.
Full supervision, timely detection and timely correction.
A quality control team was set up in Station C to analyze and rectify the medical quality of the whole station in that month.
2. Formulate and improve the standardized operation system of medical quality.
First, improve the job responsibilities of the directors of all subjects and departments, actively study their own job responsibilities and earnestly perform their duties.
B, formulate the following rules and regulations:
1), medical complaint handling system, 2), implementation of medical core system, 3), infectious disease prevention and control system,
4), nosocomial infection work system, 5), prescription review and medical record review work system, 6), disinfection and isolation system, 7), drug and device management system, 8), medical document standardization and management system,
9), personnel training, self-inspection, monitoring system of key departments (10), personnel responsibilities, etc.
C, conducted training.
1), strengthen basic training and nursing training twice; Business study in the whole hospital for 4 times; The pass rate is 98%.
2) Standardize the management of drugs and devices, strengthen training, correctly classify and clearly identify them, which are related to medical treatment.
Nurses can skillfully operate equipment and medicines.
3) Strictly implement relevant systems and responsibilities, improve medical records, and standardize inspection application forms and reports.
Single, outpatient log, outpatient prescription.
4) Open and transparent various charging standards.
Third, the awareness of preventing medical disputes has improved.
Take medical safety as the eternal theme of service station development, pursue Excellence and continuous improvement, not seeking the biggest, but seeking the best.
1. In order to implement the safety management system of gas stations and form the consciousness that everyone in gas stations cares about safety and everyone participates in safety, in practical work, we have mainly done the following work:
First, widely publicize and strengthen education. By holding lectures, offering legal courses and safety education courses in the station, the staff's awareness of preventing medical disputes is enhanced.
The second is to strengthen the construction of professional ethics as the carrier. Enhance employees' sense of safety responsibility.
The third is to regularly go deep into the department to carry out major investigations on potential safety hazards. In accordance with the requirements of all directions and no dead ends, the rectification is in place. Establish a ledger for the identified security risks, implement the responsibilities, and rectify them within a time limit. The fourth is to standardize external advertising and publicize the technical level of the scope of practice of the unit.
2. Improve the safety management system
Perfecting the responsibility system of safety management personnel: All departments of gas stations should appoint the person in charge of safety work in relevant positions according to the requirements of "who is in charge, who signs and who is responsible for the organization", so as to strengthen the sense of responsibility of safety management personnel in the station and facilitate the supervision and situation reporting of functional departments. It is necessary to improve the record system of archives management. Establish a standardized file for safety work arrangement, inspection and rectification of the whole station, and accurately record the daily work of safety management. Establish a bottom-up safety risk reporting system in the station. The potential safety hazards of each post should be reported to the competent leader, and those within the scope of authority should be seriously solved.
3, grasp the characteristics of gas station safety.
First, we must grasp the subtleties of security risks. The security risks in the station are often caused by a small negligence in a certain aspect, a non-standard link, and a non-implementation of a certain procedure. Some small mistakes can easily lead to accidents. Second, we must grasp the universality of security risks. The work in the station involves all aspects of medical activities, and there are hidden dangers in every link and moment. Security issues are ever-present. Third, we must grasp the potential security risks. The hidden danger comes from paralysis. Paralysis in consciousness, relaxation in thought and rudeness in behavior are the biggest potential hidden dangers.
Through this review, we clearly realize that there are defects and deficiencies in the previous work, which is not our ultimate goal. We will adhere to the principle of "continuous improvement" and do the following:
1. Fully consolidate the results of this rectification, and take medical quality and medical safety as the center of service station management according to the existing scheme, making it deeper, finer and more standardized.
We should pay special attention to the training of employees, especially the new employees. In addition to the training of job responsibilities, rules and regulations, service norms and behavior norms, the focus is on job skills, skills training and three basic training. Only after passing the training can they officially take up their posts.
3, the job responsibilities, rules and regulations, operating norms as the code of conduct of the whole station.
4, it is strictly prohibited to use doctors without medical qualifications to manage patients and prescribe.
Community health service station
Month, day, two years