Part I of the test department medical safety self-inspection report
According to the requirements of the medical quality and safety of health care institutions to rectify the activities of the hospital, our hospital on the key departments, the key departments to carry out a comprehensive inspection. Now on the results of self-examination and corrective comments, measures and specific corrective responsibility to implement the report is as follows:
A review of the basic situation of medical quality and safety management in our hospital:
(a) Our hospital has a sound safety management system, with clear duties and responsibilities. We have developed a medical quality and safety management program and assessment standards, sound and perfect the medical management system duties. Medical quality management in accordance with the requirements of the management program and assessment standards, regular in-depth departments to carry out supervision and inspection, supervise the implementation of the core system, the results of the inspection in the form of quality points linked to the hospital's performance appraisal program, and effectively promote the quality of medical care and medical safety management of the continuous improvement.
(2) Strengthened the medical quality and medical safety education, medical staff's safety awareness is constantly improving.
We carry out quality and safety education for all staff in the form of safety conferences, and sign safety responsibility letters with relevant personnel in each department. We have strengthened the training and assessment of laws, regulations and rules. Training on "medical quality and safety" has been organized. After the end of the safety inspection, the hospital quality control section held a meeting to seriously study and analyze the problems and disputes found during the inspection, identify the core issues and corrective measures, and then held a meeting of the section chiefs, head nurses, business backbone quality assessment, effectively promoting the improvement of the quality of medical care.
Strengthen the three basic, three strict training and assessment, in accordance with the beginning of the three basic training and assessment plan, each department must be assessed once a quarter, the Medical Department, the Department of Nursing every six months must be held a hospital-wide three basic assessment, reference rate, pass rate must reach more than 95%.
(C) improved the prevention of medical malpractice disputes, prevention of accidental injury caused by non-medical factors of the plan, the establishment of a medical dispute prevention and treatment mechanism.
(4) Nursing management
(1) nursing management organization
able to implement nursing management in strict accordance with the provisions of the Nurses Regulations, the organization of the head of nurses and nursing staff to seriously study the "Nurses Regulations", to ensure that they are aware of the law, abide by the law, and practicing in accordance with the law.
(2) Nursing human resources management
The annual development of nurses in-service training program, including three basic learning, business lectures, nursing room. According to the plan to seriously implement the completion.
(3) Clinical nursing management
Establish the concept of humanized service, to ensure that the patient's informed consent is put into practice. A standardized plan was designed to implement preoperative visits and postoperative return visits for perioperative patients. Each department attaches great importance to health education and has developed health education content.
(E) Hospital infection management
(1) The establishment of a sound hospital infection management organization.
(2) The work responsibilities of the hospital infection control management organization have been implemented.
Our hospital according to the actual situation and task requirements, the annual development of hospital infection management work plan, to achieve the implementation of the organization, responsibility. Each year, a hospital infection management meeting is held to summarize the recent hospital infection management work, to solve the general problems found in the daily work, and to set up the focus of the next period of work.
(3) strengthened the knowledge of hospital infection management training, and constantly improve the awareness of hospital infection control and sterilization isolation of health care workers.
(4) seriously carried out hospital infection control and disinfection and isolation monitoring work, reduced the rate of hospital infection, never occurred hospital infection outbreak epidemic phenomenon. The management of single-use supplies has been strengthened. The departments strictly implement the "one-time use of sterile medical supplies management methods", one-time use of medical and sanitary supplies by the equipment section of the unified purchase, storage and distribution, "three certificates" complete. Each department receives the supplies according to the need, so as to use them first and use them within the validity period. Single-use supplies after use, by the person centralized recovery, prohibit re-use and return to the market.
Second, there are problems:
(a) Some of the medical management system is not enough to implement the place.
Individual medical personnel quality and safety awareness is not high enough, the first physician responsibility system, case discussion system and other core systems sometimes can not be well implemented, case discussion and coping with the situation.
(b) The application of antimicrobial drugs still exists irrational imagination.
Individual medical staff antimicrobial drug use is unreasonable, the common cold also use antibiotics; surgical perioperative prophylaxis is unreasonable, antibiotic application grade is too high, too long.
(C) There are still many problems in the writing of hospitalized medical records.
1, the course of the record of the revised medical advice, positive test results lack of analysis, the content of the analysis of the room less, some like a running account.
2, the existence of informed consent omitted signature, self-financed medication not signed informed consent.
Third, corrective measures:
(a) to further strengthen the quality and safety education, improve the safety of medical staff, quality awareness.
The medical staff generally exists to pay attention to professional knowledge and despise the learning of quality management knowledge, lack of quality management knowledge, quality awareness is not strong, so that it can not consciously and actively apply the quality requirements with the daily medical work, it is difficult to ensure that the quality of the goal is achieved. Quality management is a discipline, in order to improve the quality of medical care, it is necessary not only to learn medical theory, medical technology, but also to learn the basic knowledge of quality management, constantly update the concept of quality management, and adapt to the needs of society. Only by making the medical staff establish the correct quality management consciousness and master the quality management method, can they change the passive quality control into active self-quality control. Therefore, training all medical staff in quality management knowledge and enhancing quality awareness is one of the basic tasks to improve medical quality. First of all, it is necessary to strengthen the training of medical related laws, regulations, rules and regulations, and duties of personnel at all levels. Our hospital has spent great efforts on system construction, compiling various laws and regulations, systems and duties of personnel at all levels. To seriously organize the study of "hospital staff duties", "hospitals commonly used laws and regulations selected", "medical quality and safety management manual", medical staff must master the relevant laws and regulations, the core system, personnel duties, in March to organize a full medical skills, regulations, systems, duties and other related knowledge assessment, the results are recorded in the personal file. Strengthen the quality of medical staff to learn the basics of management, improve the quality of medical staff awareness, safety awareness and awareness of prevention.
(2) Increase supervision and inspection efforts to ensure the implementation of the core system.
1, the medical department to further strengthen the quality of room and running medical records inspection work, this work to improve the quality of medical care is a very good measure, but to focus on the effectiveness, can not be a formality, on the problems found in addition to face-to-face explanation of the problem, the repeated offenders must be punished through financial penalties, to give disciplinary action.
2, to strengthen the three basic training and assessment, we must continue to improve the assessment methods, serious assessment discipline, pay attention to the effectiveness of the assessment, not a mere formality. The head of the department should pay attention to the three basic training, and often speak to the medical staff about the importance of the three basic learning, which is essential to improve the technical level of medical staff.
3, strengthen the management of case quality.
To further improve the relevant systems and medical records inspection standards, in order to develop incentives and penalties to ensure that the timely filing of hospitalized medical records and the safe flow.
4, to further strengthen the monitoring of hospital infection.
To further in the hospital infection case monitoring, disinfection and sterilization effect monitoring, environmental hygiene monitoring and other work up and down, the strict implementation of the hospital infection management system, to do the work in detail, can not cope with. To further increase the knowledge of hospital infection training and publicity, so that each medical staff to recognize the importance of hospital infection control, consciously abide by the aseptic operation techniques, and do a good job of personal control links. Play the role of departmental hospital infection control team, with the Hospital Infection Office to actively carry out the work, to eliminate the underreporting of hospital infection events.
5, to further strengthen the management of the use of antibacterial drugs.
According to the Ministry of Health "to further strengthen the management of the clinical application of antimicrobial drugs" notification spirit, the development of our hospital specific implementation methods and rewards and punishment system, focusing on monitoring the perioperative preventive drug use. To further implement the antimicrobial drug hierarchical management system, set prescription authority in outpatient workstations to ensure the implementation of the system. Improve the rate of bacterial culture and drug sensitivity test to ensure the rational use of anti
Part II Medical Safety Self-Investigation Report of the Laboratory Department
According to the 'Baoding Municipal Bureau of Health's report on the issuance of the "ⅩYear of Baoding "Medical Quality Wanlihang "activities of the implementation of the program" of the notice 'spirit of the work of my section of the self-examination, that: under the leadership of the hospital, the work of the Laboratory Division, the achievements are gratifying, but there are also shortcomings, the need for continuous improvement in the future work.
1, all comrades in the Laboratory seriously study and practice the scientific concept of development, adhere to the people-oriented, patient-centered, pay attention to the service links and details of the management, pay attention to improving their own business quality and moral integrity, are able to proactively ` participate in the work of the department, with a high degree of awareness of the quality of medical care and medical safety, pay attention to their own images, behaviors, language, and give the patient true communication, warm service. Correct use of civilized language, and patients have a cordial relationship, get the majority of patients praise. No quarrels and medical disputes with patients.
2, the continuous improvement of service quality, to ensure medical safety is the core of our work in the department, the development of a variety of systems necessary to urge everyone to follow. And in the actual work of continuous supplementation, continuous improvement.
3, able to carry out bacterial culture and drug sensitivity tests, equipped with biological safety cabinets, incubators, autoclaves, ultraviolet disinfection and other equipment, and training professionals responsible for the work, with a high degree of awareness of biosafety and work quality. Does not have the ability to test activities of highly pathogenic pathogenic microorganisms.
4, the Laboratory is equipped with a variety of large-scale instruments and equipment: automatic biochemical, five categories of blood cells, automatic hemagglutination, biosafety cabinets, etc., the establishment of the instrumentation file, usually focus on the maintenance of the instrumentation maintenance and repair, to ensure the safety of operation.
5, the fire channel is smooth, no obstacles.
6, there is no dedicated room in the blood bank, the completion of the new building can be improved, dedicated blood storage refrigerator can be in place in a few days.
In the future, we will continue to work hard to improve the quality of service, and constantly improve various rules and regulations, equipped with special blood storage refrigerator, plasma lyser, and other equipment, better service for the majority of patients.
Part III of the laboratory medical safety self-examination report
In the hospital's leadership attention, for the current existence of certain medical units of bad medical behavior, the whole hospital has carried out a comprehensive self-examination and self-correction of the work of the inspection. Laboratory Department of the management of the section, quality, safety, service and other aspects of a comprehensive self-examination and self-correction checks. After three days of self-examination and self-correction, against the relevant medical rules and regulations, found a number of hidden dangers, the development of relevant measures. Briefly summarized as follows:
1, the quality of specimens most of the specimens qualified, unqualified specimens have a record of rejection and re-sampling treatment. Problems: insufficient communication with the Nursing Department and nursing care in various districts to reflect the quality problems in blood sampling in a more comprehensive and timely manner. Measures: Quarterly will be related to the quality of specimens in the form of a table to reflect to the nursing department, in order to promote the improvement of the quality of pre-test.
2, indoor quality control all carry out the project can adhere to the daily indoor quality control, there are records, the point of loss of control has been analyzed, there is treatment. Quality control is good.
3, inter-room quality control can participate in the annual Foshan City, Guangdong Province, the Ministry of Health of various types of projects inter-room quality. There are records and feedback analysis, strict control of the person in charge of quality. The same type of analytical instruments have measured the value of regular comparison, the data show that the results between different analytical instruments in a reasonable acceptable range.
4, the critical value reporting system of each laboratory can be seriously implemented, there are records and processing. Problems, found 1 case of false critical value improper handling. Measures: Strengthen the staff's business ability to learn and training, and constantly improve their own professional ability. The handling and reporting of critical values are standardized and implemented. Require everyone to pass the test.
5, on dangerous goods, safe use of electricity, fire hazards inventory. Hazardous materials are managed under lock and key, and there is a registration of use. Did not find electricity, electrical use of safety hazards. No potential fire hazards were found. Firefighting equipment qualified and stored in accordance with the requirements.
6, the service ability to send reports on time, the inspection report timely rate of 95%. Service satisfaction of 90%. Rating for the time 84 points. Service level and quality still need to be continuously improved. Strengthen the ideology and professional ethics education, establish a new style of the industry, create a civilized service window.
The self-examination and self-correction inspection, to improve the quality of our test has a great role in promoting the protection of medical safety, to eliminate medical hazards has a positive significance.