Self-examination report of a hospital
Since June 20xx 1 day, our county has gradually implemented standardized management of township hospitals. Through convening a mobilization meeting, issuing implementation plans, defining work objectives and tasks, and formulating work measures, pilot projects were carried out in some township hospitals and gradually pushed out throughout the county. So far, this work has been fully implemented in the county 13 township hospitals. According to the requirements of the superior, the progress of the pilot work of standardized management of township hospitals in our county is reported as follows: 1. Work achievements.
1. Through the standardized construction of clinical departments and vaccination clinics in traditional Chinese medicine hospitals for public health and environmental construction, the infrastructure construction of department configuration, medical equipment configuration and use, and post appointment of professional and technical personnel in township hospitals has been further improved.
2. Through the unified management of people, talents and materials in township hospitals, the hospital has straightened out the management system of township hospitals in terms of technical personnel deployment, qualification access, fund investment, asset management, business guidance and work coordination, public health and medical market supervision.
3. The reform of personnel distribution system in township hospitals has been completed. On the basis of implementing the target responsibility system of the president's term of office and perfecting various management systems, the department setting of township hospitals is divided into public health and medical treatment, and it is clear that all township hospitals should focus on public health services. On this premise, the central hospital should further improve the level of medical technology and guide the business work of the surrounding general hospitals. A strict performance appraisal system has been established, and the salary distribution of personnel is linked to the services provided and labor contributions, which improves the internal vitality of township hospitals and stimulates the enthusiasm of cadres and workers.
4. The hospital's administration and business have been institutionalized. Formulate the class objectives and tasks of hospital leaders and department heads. The post responsibility system combining responsibility, right and benefit shall be implemented, and various medical and nursing work systems such as handover of clinical departments, standardized writing of medical documents, registration of errors and accidents, disinfection and isolation shall be established and improved to prevent medical disputes and put an end to medical liability accidents.
5. Actively carry out counterpart support work of rural health institutions, arrange five county-level medical and health institutions to provide counterpart support to 13 township health centers, and take charge of the responsibility system of 248 village clinics in the county according to the regional arrangement 13 township health centers, effectively establish and improve the rural three-level medical and health network infrastructure, and give full play to its due role. By signing the counterpart support agreement, the work objectives, tasks, working methods, time, responsibilities and rights of both parties have been clarified, the management and service capabilities of grassroots medical and health institutions at all levels have been improved, and the environmental construction and connotation construction of recipient township hospitals and village clinics have undergone significant changes.
6. Strengthen the management of accounting, health care and prevention professionals, women and children professionals, combined therapy professionals and other full-time personnel in township hospitals, and formulate measures for the employment and assessment of all professionals. All professionals must be declared by the hospital and approved by the Health Bureau before they can take up their posts. Without the permission of the superior, the hospital is not allowed to change at will, which ensures the stability of the full-time staff of the hospital and effectively promotes the smooth progress of financial and health work.
7. Formulated and issued the "Ten Provisions for the Dean of Township Health Centers in Huaxian County", which strengthened the management of the directors of health centers. It is clearly required that hospital directors should carry out all work in accordance with relevant national laws and regulations, obey the management of the Health Bureau, ensure the smooth implementation of government decrees, and strictly demand themselves in accordance with the Ten Provisions for the Directors of Township Hospitals in hua county to complete all tasks on schedule.
Second, the existing problems
1. Due to historical reasons, some township hospitals are short of technical personnel and small in scale, and the existing medical equipment cannot play its due role. Solution: It is being solved through temporary secondment and entrusted training.
2. The distribution of medical equipment resources is uneven. Solution: Through investigation and statistics, the Health Bureau uniformly registered, repaired, maintained and debugged all the damaged and idle medical equipment in township hospitals throughout the county, and then re-deployed them. In order to improve the utilization rate of equipment and facilitate the people to seek medical treatment.
3. Effectively combine the internal similarities and differences of standardized construction of village clinics, standardized management of township hospitals and integrated management of rural health services, and make scientific and reasonable arrangements, which greatly improves work efficiency.
Self-inspection report of the Second Hospital
In order to strengthen my work quality, model medical action, eliminate hidden dangers of maintaining stability and ensure the stability of patients, I conducted strict self-examination and self-correction according to the accidents in pediatrics and the detailed environment of our department. Now please consult the following about the environmental protection report of self-inspection: 1. Poor awareness of medical risks.
2. Weak legal awareness.
3. Doctor-patient similarity skills are not enough.
4. The opinion of teamwork is not strong.
5. The level of professional skills needs to be further improved.
In view of the above, we should do:
1. At work, we must strictly abide by laws, administrative norms, some rules and regulations of medical and health management, and the patterns and old habits of medical and nursing staff, and adhere to the professional ethics of medical affairs.
2. Repeatedly study the medical and health laws, standards, rules, models and old cases of nursing and assisting nurses in diagnosis and treatment, improve their legal awareness and set an example for nursing and assisting nurses.
3. In the activities of nursing staff in medical care, the patient's condition, medical methods (treatment or surgical plan, examination items, drug types, etc.) should be informed. ) and medical risks (complications, accidents, drug side effects, etc.). ), and their inquiries should be answered in time. It is forbidden to use irritating words or words that have adverse effects on the treatment and recovery of patients' diseases, and pay attention to the way, methods and skills of speaking.
4. Accurately use the informed notice and power of attorney of patients or relatives.
5. Nurses must be objective, true, accurate, timely and complete in accurately copying documents. It is not allowed to whitewash or remove the original handwriting by scraping, gluing or painting.
6. Strengthen teamwork spirit and cooperate with medical education network for internal collection and sorting.
7. We should automatically learn advanced medical knowledge, improve our professional skills, improve medical quality and serve patients well. At the same time, we should strengthen the study and cultivation of humanistic knowledge and etiquette knowledge, and strengthen our own similar skills.
8. Be responsible and kind to patients; Memorize the core medical system and strictly implement it in actual clinical work.
9. In practice, we should:
Pay attention to what you say; Explain clearly.
Check carefully; The records should be intact.
The system should be strict; Proficient in skills.
Manipulation should be exemplary; Help should be in place.
Article 3 Hospital self-inspection report
In order to do a good job in hospital safety, according to the spirit of the document of the Health Bureau and other superior departments, the leading group for safety production in our hospital carefully organized and studied the spirit of the document, conducted investigations in strict accordance with the requirements, and seriously solved the existing problems. The self-inspection is now reported as follows: 1. The leading group of safety students in our hospital organized relevant personnel to conduct self-examination on the scope of X key safety requirements, and successively inspected and maintained the facilities and facilities such as outpatient service, ward, X information network facilities, canteen, crowd gathering place, finance department, warehouse, pharmacy and other key parts such as power distribution room, water supply and drainage facilities, pressure vessels, etc., especially the key equipment and facilities such as water and circuits in the whole hospital.
Second, the X safety leading group is well organized, and all subjects have set up safety teams. The person in charge of each subject is an undergraduate safety officer, with clear responsibilities and safety production management regulations and safety production systems. Outpatients, wards and other personnel gathering places are safe, fire-fighting facilities such as fire hydrants and fire-fighting equipment are inspected in good condition, and evacuation passages are smooth; Call the staff of the whole hospital to carry out the special education of "fire fighting knowledge" in batches, and describe in detail the use of fire extinguishers, how to guide patients to escape in case of fire, and improve the fire fighting awareness of the staff.
Third, organize the deployment of the backbone of the X department, led by the competent dean, and actively participate in the fire drill organized by the X District Health Bureau, as a representative to further improve the actual combat ability of the hospital staff.
Four, organize relevant personnel to carry out the investigation of contradictions and disputes in the hospital, and actively resolve the unstable factors. X takes the self-inspection of production safety as an opportunity to find potential safety hazards in time and effectively curb accidents.
Fifth, do a good job in medical safety. Hospital leaders held a meeting of department directors and head nurses in time to carry out special medical safety activities around the theme of "patient-centered", unify their thinking, raise awareness, organize medical quality education for all staff, and raise medical safety awareness. The leaders of the hospital carried out extensive inspection in the whole hospital, implemented the medical management system and operating procedures, implemented various rules and regulations to control X infection, and strictly implemented hand hygiene standards and strict disinfection and isolation systems. Do a good job in toxic drug management, high-pressure sterilization and disinfection, do a good job in biological monitoring and environmental monitoring, strictly investigate quality links, eliminate potential safety hazards, and provide a harmonious and safe medical environment for the people.
Through self-examination, the staff of the whole hospital have improved their awareness of safety production and clarified their responsibilities. Ensure that safety production is implemented in daily work.
Article 4 Hospital self-inspection report
Fire control work is an important daily work of the unit, which is related to property safety, personal safety, social stability and economic development. At present, it is a period of high fire incidence, and all kinds of unsafe factors are increasing, which can easily lead to fire accidents. According to the fire safety training instructions of Chengdu Public Security Fire Bureau, the hospital conducted a comprehensive inspection of the fire facilities in the hospital on May 20 in the attitude of being responsible for the unit, the medical staff, the patients and the society. Check. The inspection and rectification are now reported as follows: 1. Self-inspection.
(a) the hospital floors and wards, office safe passage instructions complete and clear. The emergency lights are undamaged and the power supply is good, which can meet the evacuation requirements.
(2) The whole hospital is equipped with 14 dry powder fire extinguisher and four fire hydrants. There are 1 fire hydrants on each floor, with an average of 4 fire extinguishers on each floor. It can be used normally after inspection.
(3) The wiring of the whole hospital was reformed last year, and wires, switches, sockets and switches were re-purchased and installed according to relevant standards. Patients are forbidden to boil water and cook in the ward, and the wires are intact.
(four) the floors of the fire pipeline unobstructed, sufficient water, reasonable pipeline layout, can work normally, in line with fire safety requirements.
(E) Hospital fire prevention system is not perfect.
Second, the current fire situation assessment
Through this inspection, it is found that the fire control work in the hospital is generally good, but there are still many shortcomings and some fire safety hazards. The most prominent thing is that the number of fire extinguishers is not enough and the key parts are not equipped. The unusable ones were not replaced in time. In addition, the fire safety prevention system is not complete, and some staff members lack fire safety knowledge, fire awareness and self-protection ability.
Third, the rectification measures
(a) the fire safety work as an important work to grasp, the main leaders personally deployed, business dean personally grasp. The responsibility for key parts lies with people. The outpatient department is responsible for internal surgery and radiology; The doctor in charge of the inpatient department; The office area and staff canteen are in the charge of the hospital.
(2) The hospital should establish a fire inspection and disposal system, and the first person responsible for finding fire hazards must handle and report in time. During fire fighting and disaster relief, all the staff should work together with Qi Xin, cooperate with each other, and jointly provide disaster relief.
(3) equipped with 14 dry powder fire extinguisher, placed in key parts. There are four inpatient departments on the first floor, four inpatient departments on the second floor, four inpatient departments on the third floor and two staff canteens. At present, you can use 12 fire extinguishers, and you are going to buy two.
(4) Conduct fire safety inspection activities in the whole hospital from time to time, handle any potential safety hazards in time and eliminate them.
Article 5 Hospital self-inspection report
According to the Notice of state administration of traditional chinese medicine Office and the General Office of the National Health and Family Planning Commission on Printing and Distributing and the Implementation Plan of the Provincial Health Planning Commission and the Provincial Bureau of Traditional Chinese Medicine; In response to the call of our city to organize a special inspection on the management of Chinese herbal pieces in medical and health institutions in the city, recently, the quality management leading group of Chinese herbal pieces in our hospital conducted a comprehensive self-examination on the procurement, storage, deployment, decoction, prescription management and comments of Chinese herbal pieces in our hospital. The self-inspection report is as follows: 1. Management status of Chinese herbal pieces in our hospital.
1, and established the management organization. Our hospital has set up a leading group for quality management of Chinese herbal pieces, headed by President Liu Jinghong personally, to strictly manage the procurement, storage, deployment, decoction prescription management and comments of Chinese herbal pieces, so as to ensure the quality of Chinese herbal pieces and the safety and effectiveness of clinical medication.
2. Procurement and acceptance management of Chinese herbal pieces. Can be strictly in accordance with the provisions from the "drug production license" of Chinese herbal pieces production enterprises or "drug business license" of Chinese herbal pieces business enterprises to buy Chinese herbal pieces. When purchasing Chinese herbal pieces, they can be checked and accepted in strict accordance with the national drug standards and the standards and norms formulated by the provincial drug supervision and management departments, including quality, specifications, quantity, packaging, labels, certificates, etc. Each piece of Chinese herbal medicine must be accompanied by the quality inspection report of the drug supervision department, and the person with intermediate title and experience in identifying Chinese herbal medicine pieces is responsible for the acceptance and signature of Chinese herbal medicine pieces before it is qualified. Those who fail to pass the inspection will never be put into storage, and counterfeit and shoddy drugs will be prevented from entering our hospital from the source.
3. Storage, storage and maintenance of Chinese herbal pieces. Our hospital has set up an independent warehouse of Chinese herbal pieces, which has perfect conditions and facilities such as ventilation, temperature regulation, humidity regulation, moisture prevention, insect prevention, rat prevention and theft prevention, and is managed by a special person and checked every day. So as to completely prevent the occurrence of problems such as moldy deterioration, discoloration, moth-eaten, rodent damage and the like of Chinese herbal pieces.
4, Chinese herbal medicine dispensing management. Dispensing personnel in Chinese pharmacy strictly implement the management system for dispensing Chinese herbal pieces, resolutely refuse prescription dispensing that may cause drug safety problems, such as "eighteen evils", "nineteen fears", contraindications to pregnancy, and exceeding the dosage specified in China Pharmacopoeia, and require the prescriber to confirm (double sign) or re-issue the prescription before dispensing. Special decocting methods such as decocting first, decocting later and packaging can be indicated on the medicine bag.
5, Chinese medicine decoction management. The decocting room of our hospital is equipped with two multifunctional automatic decocting machines, which can basically meet the relevant requirements of soaking, frying twice, stirring, frying first and frying later. A relatively perfect operating rules and scientific and reasonable Chinese medicine decoction process have been established, which can operate Chinese medicine decoction pieces with special requirements, such as frying first, then frying, dividing, melting, decocting in water, etc., according to requirements or doctor's advice, and ensure the decoction quality of Chinese medicine decoction pieces.
Second, the existing problems
1. There are few equipments in the decocting room of our hospital, which can only guarantee the basic requirements of patients' decocting decoction pieces. At the same time, due to the lack of staff in Chinese pharmacy, it failed to play a perfect work efficiency.
2. Limited by the professional direction of the staff of the prescription review working group in our hospital, we failed to establish a perfect special review system for prescription of Chinese herbal pieces, and also failed to carry out the related work of prescription review of Chinese herbal pieces smoothly.
Third, the rectification measures
1. Our hospital rationally allocates and adjusts the personnel composition of Chinese pharmacy to ensure the smooth completion of the dispensing and frying of Chinese herbal pieces, ensure the work efficiency, and ensure the timely, safe and rational use of drugs by patients.
2 to strengthen the professional training of the staff of the prescription management review team, establish and improve the special review system of Chinese herbal medicine prescriptions in time, and ensure the smooth development of the relevant work of Chinese herbal medicine prescription review.
In this self-inspection operation, we found that there are still some problems and deficiencies in the work. Our unit will strictly abide by the requirements of the drug supervision department, actively carry out business study and self-examination to ensure the rational and safe use of drugs by patients.
Article 6 Hospital self-inspection report
In order to implement the "Hospital Management Year Activity Plan" of the Ministry of Health and the unified arrangement of hospitals and departments, the medical technology department, by studying, combined with the basic situation of the undergraduate department and in accordance with the requirements of carrying out the "Hospital Management Year Activity Plan", clearly defines the importance of strengthening the connotation construction and internal management of medical institutions, improving the quality of medical services, ensuring people's health and life safety, promoting the healthy development of medical and health undertakings, and implementing self-examination and self-correction through learning and comparison to solve existing problems. The development of hospitals does have hidden dangers in medical safety. The main reasons behind these problems are inadequate implementation of departmental systems, weak safety awareness, lax management and supervision, and neglect of connotation construction. Under the background of current medical and health system reform, it is particularly important to strengthen industry management, stabilize medical order and ensure medical safety. With the theme of "patient-centered, improving medical quality", the medical diagnosis technology is searched and sorted out, and targeted measures are taken to eliminate all kinds of hidden dangers unfavorable to patients. Establish a long-term management mechanism. We will thoroughly implement the core system and standardize various inspection procedures. Carefully complete the inspection report and provide effective diagnosis suggestions for patients in clinic.
Establish an orderly workflow, B-ultrasound, color ultrasound in the case of many patients, the inspection process is chaotic, some patients wait too long, family members have opinions, there are arguments, for this, we must set up an inspection registration window, in accordance with the inspection order, (except emergency). In order to prevent scrambling to induce contradictions. The number of patients receiving B-ultrasound examination increased significantly. At present, the two sets can no longer meet the needs of the development of the situation. To increase the quantity, print the report by computer and standardize the report form of the checklist. The results of the inspection report shall be signed by the examining doctor and issued. The shortage of B-ultrasound medical technicians should be solved as soon as possible. Solve the duty regulations, implement the post to the person, and implement the 24-hour duty system.
In the endoscopy room, most people are late for work, anesthesiologists are not in place on time, and patients often wait too long. The inspection shall be conducted on a first-come-first-served basis. Nurses in gastroscope room should strictly disinfect gastroscope equipment, pay attention to the concentration and effective time of disinfectant preparation, and prevent hospital infection. In terms of the quality of medical diagnosis, the examination should be meticulous, the work should be recognized and the attitude should be harmonious. Everything should be done according to the operating specifications to prevent mistakes. Check the colonoscopy in the morning and afternoon, and do a good job of cleaning and washing the intestine before the examination. Everything should be for the sake of patients, solve the problem of difficult and expensive medical treatment, and realize the lofty concept of sincere service for patients.
The new equipment 16 slice spiral ct has been developed for more than half a year. Up to now, it has basically met the needs of clinical examination, but it has not yet played the role of full-effect examination, and gradually developed the scope of examination to a wider and deeper aspect, opening up new projects. Although many achievements have been made so far, there are still many problems.
The implementation of the system is not in place, and the operating procedures are not standardized, especially in abdominal examination, which does not meet the requirements of patients before examination, affecting the image quality and causing the quality of diagnosis to be blurred.
The quality control of diagnosis is not strict, and there are misdiagnosis and missed diagnosis. In terms of quality control, we should intensify our efforts to implement a three-level film censorship system and make more efforts in quality control.
Specify the shooting time and report the results. Take the film in the emergency room within half an hour, and get the results within one hour. The results of non-emergency examination were taken at 4 pm, skull examination in the morning and chest and abdomen examination the next day 10. All patients with abdominal examination should be scanned and enhanced, and the payment should be made at one time, so as to reduce the trouble of patients paying back and forth.
Accelerate the business knowledge study of new projects, take the examination of various parts of vascular images as the main research topic in the future, carry out three-dimensional reconstruction of images, and more importantly, accelerate the development of ct diagnostic technology, and gradually improve the professional and technical diagnosis level through short-term training and online discussion.
The discussion of difficult cases is not standardized. There is no perfect system, doctors' opinions are not recorded and archived, and cases are tracked and fed back, lacking in serious summary. In this regard, we must set out to improve and establish a long-term mechanism, formulate effective measures and plans, focus on film reading, case discussion and analysis, review inspection reports and case tracking records, constantly sum up, study new technologies, start innovative projects, give full play to the functions of 16-slice spiral ct, ensure good quality, speed up the study of technical knowledge such as vascular imaging, endoscopic simulation and three-dimensional reconstruction, and improve the professional diagnostic technology of ct images.
Poor awareness of labor discipline, being late for work, not implementing the rules and regulations of hospital departments, and sometimes causing complaints from patients' families after work. At present, B-ultrasound, color ultrasound and ct have all implemented a 24-hour duty system. It solves the problem that emergency patients are on call.
By studying and implementing the activity plan of hospital management year, we further advocate the concept that medical staff should think of patients in everything, solve the problems of difficult and expensive medical treatment and serve patients wholeheartedly. To provide quality services for patients, accelerate the overall planning and development of the hospital, * * * Qi Xin makes concerted efforts.