First, the quality of nursing quality control principles:
Nurse manager - department nursing quality controller - all nurses involved in quality management monitoring, implementation of the continuous improvement of nursing quality, the full implementation of quality control work.
Second, the implementation of nursing quality management program:
(a) further improve the nursing quality standards and workflow.
1, combined with clinical practice, and constantly improve the quality control system, and further improve the nursing quality assessment content and scoring standards, such as ward management, basic care, special, first-class care, disinfection and isolation, the writing of nursing documents, first aid goods management, nursing safety management, etc., and nursing quality assessment and analysis every month, and formulate the corresponding corrective measures.
2, the head nurse, departmental nursing quality control officer at any time to monitor and correct the problems in the nursing work in a timely manner, the problem of outstanding in the morning meeting for the notice, so that nurses know the existence of the problem and the solution to the problem.
3, regular monthly inspection of various items and drugs, emergency vehicles, timely detection of expired items and drugs. To ensure the safety of medical care.
(2) the establishment of an effective nursing quality management system, the formation of a group of nursing staff with extensive work experience to participate in nursing quality control, in order to protect the quality of nursing work.
1, the implementation of the quality control network to the head nurse, departmental quality control officer, and gradually implement the participation of everyone in quality management, to achieve the goal of full quality control.
2, play the role of nursing quality monitoring group, focusing on link quality control and key issues of rectification effect tracking. The implementation of the principle of combining the usual inspection and monthly inspection, focusing on the combination of comprehensive inspection.
3, increase the implementation, supervision, inspection efforts, pay attention to the quality of the nurse operation process supervision. Grasp the quality control management, so that everyone participates, *** with the gatekeeper, to ensure quality, give full play to the work of nursing quality control officer, full participation in nursing management, inspection records, analysis, evaluation and improvement measures.
4, improve the nursing quality control management system, responsibilities, the existence of difficult problems in nursing to discuss, analyze, put forward effective corrective measures.
5, strengthen the management of nursing defects, nursing disputes, adhere to the strict supervision of the quality of each work link, found that the security risks, take timely measures to nip nursing errors in the bud.
6, strengthen the medical care laws and regulations of training to improve the legal awareness of nursing staff, according to the law from the nursing, protection of patients and nurses of their own legitimate rights.
7, strengthen the nursing staff formal operation, and assessment. Timely detection of problems in the operation and timely correction.
8, each class of nurses every shift to check the medical advice, the head nurse weekly check to ensure the correct implementation of medical advice.
9, the daily nursing document writing check, discharge medical records by the nurse in charge of the initial review, the head nurse last review to the case room.
10, the establishment of nursing safety management, nursing safety knowledge training every month, explaining the hospital hospital and outside the hospital nursing problems, in order to strengthen the safety awareness of nursing staff, and sound safety early warning work, timely find nursing safety hidden danger, the implementation of the weekly focus on finding the safety problems, and analysis, and put forward improvement measures.
Quality control work schedule (Part 2)First, the department of three-level nursing quality control management
(a) to the head nurse, a nursing backbone of a quality control member of the department of nursing quality control network, the implementation of the department of three-level quality control management. The establishment of six nursing quality control group, the gradual implementation of everyone involved in quality management, to achieve the goal of full quality control. Each management team regularly completes work plans, inspection records, summaries and analysis, as well as feasible improvement measures and training programs.
(b) the quality control team training department staff inspection standards and scoring rules, especially the team leader to do a good job of passing on the role of assisting the head nurse to do a good job of supervision and guidance, the liaison play the role of uploading the role of the *** with the work of nursing quality control, the head nurse regularly liaison standardized assessment.
(c) the head nurse organized a monthly "nursing quality analysis meeting", the person in charge of the quality control group will summarize the problems of the previous month and focus on the discussion, the whole department to discuss the corrective measures proposed to record the content of the meeting to the "nursing quality analysis meeting", the participants did not attend the meeting.
Second, the department of each quality control group specific work plan
(a) Nursing safety management group:
1, the implementation of the system:
(1) continue to organize the study of the various core systems and emergency response plan, and will be placed in the system and the plan in the place of easy access to facilitate the study of the regular learning and access;
(2) the implementation of the first question system of responsibility, the patient has a problem in a timely manner to solve, can not be excused;
(3) strict three checks and seven right, double-checking the implementation of the doctor's orders;
(4) doctor's orders class class checking, the wrong doctor's orders did not check the discovery of checking the person with the treatment of the person who bears the same responsibility;
(5) timely play the role of the general checking of the monitoring of the doctor's orders, the chief of the total weekly nursing checks (6) Strict implementation of the medical prescription process, non-rescue time does not implement verbal medical advice, supervision and management in place;
2, falls, pressure ulcers:
(1) according to the fall, pressure ulcer assessment system in a timely and correct assessment, there is a continuous tracking;
(2) for the department's high-risk groups and high-risk links for monitoring, timely detection, and the most important thing is to ensure the safety of the patient's health, so that they can be protected. (2) For the high-risk groups and high-risk links in the department to monitor, timely detection, timely treatment;
(3) The team leader of the daily quality control of falls and pressure ulcer scores of the patients in the department, and the lower level nurses to do a good job of guiding;
(4) In the event of a fall or a pressure ulcer, there is a contingency plan, and know how to deal with it and report it;
3, Adverse Events:
(1) Training in the system of adverse event reporting and handling, adverse event category;
(3) Adverse event reporting and handling, adverse event reporting and management.
(2) master the adverse event reporting and processing process;
(3) nurses reported adverse events, the head nurse should be timely review, to determine the grading and classification, to help nurses analyze the reasons for rectification of the department;
(4) do a good job of building a culture of safety in the department and publicity work, and regular safety warning case study or small lectures, to cultivate nurses risk awareness and awareness of prevention;
(4) to build a good safety culture and publicity work, regular safety warning case study or small lectures. Cultivate nurses' risk awareness and preventive consciousness;
Quality controllers complete the content of the quality checklist every week according to the requirements, and do a good job at the end of each month to summarize the data, summarize the main problems of nursing safety management, and analyze the reasons, and put forward the corrective measures, corrective measures by the head nurse agreed to notify the whole staff to know, and by the quality controller to track the corrective measures to implement the situation.
(B) nursing paperwork group:
1, organizational learning and training nursing paperwork related systems, and assessment;
2, temperature list without missing items, cardiac monitoring use and critical care patients' heart rate, respiration, stool counts, must be in line with the nursing record sheet;
3, medical orders to be implemented in a timely manner to confirm that there is no omission of the signature;
4, Nursing records require a concise and fluent description of the condition, the use of medical terminology, focused, timely records, consistent with the condition, with special medication, treatment and changes in the condition of timely and accurate records;
5, the responsible team leader before the end of the day before the quality control of nursing paperwork of the small responsible class, found that the problem is timely informed and corrected;
6, N
class quality control of the five nursing paperwork daily
7, the patient was discharged from the responsibility of the class on the paperwork for the initial quality control, for obvious errors in a timely manner to modify, inform the responsible person;
8, monthly by the quality control team of at least 5 medical records, for the overall supervision, such as found to have problems with the written records, timely organization of the department to discuss, analyze the reasons, and put forward corrective measures and have a record. Propose corrective measures, and have records. The results of the inspection are linked to the personal behavioral assessment, nursing writing in all aspects of the better by the head nurse in the nurses' meeting to give praise;
Requirement of daily quality control records, rectification and tracking, by the N
Shift nurses at least 5 daily access to the medical record, and registration. The quality control officer is on time to complete the content of the nursing paperwork check on a weekly basis, and summarize the data at the end of each month.
(C) Drugs (including blood) management group:
1, drugs are classified and placed, managed by special people, and registered in a special book;
2, A6 class conducts a daily inventory of drugs to ensure that the base number and quality of drugs;
3, the drug administrator regularly counts the types and quantities of drugs every month, and if there is any sedimentation, discoloration, near-expiry date, or fuzzy labels, they will be given in time for replacement;
3, the drug administrator regularly counts the type and quantity of drugs every month. Replacement;
4, according to the type and nature of drugs, such as internal, external, injections placed in categories, obvious signs, daily inspection, the same color of the same type of oral medicines and different doses of the same type of injections shall not be mixed, the packaging is similar to the similar drugs, a product of multiple specification or multi-dose storage of drugs have obvious warning signs;
5, high-risk drugs in accordance with the implementation of the management system of high risk medicines, there are Special storage area, marking, storage method is correct;
6, first aid drugs are in standby status, regular inspection records, handover registration is complete;
7, training of safe use of blood related systems;
8, organization of training in the occurrence of blood transfusion reaction in the event of the emergency plan, so that everyone knows;
Daily A6 treatment shift nurses check the high-risk medicines. In the bottle label, infusion card stamped "anti-extravasation" high-risk chapter, infusion bottles on the red tape, the use of "high-risk drug inspection card" clip in the red infusion card, the nurse in charge of at least hourly inspection to ensure the safety of medication. When the patients in the department need blood transfusion, the nurse in A6 shift is responsible for collecting blood and cleaning and disinfecting the blood collection box every week. The quality control officer completes weekly drug and blood transfusion checks, and summarizes the data at the end of each month.
(D) emergency medicine and equipment management group:
1, rescue car is clearly labeled, five management, according to the requirements of the sealing of the car, do a good job of registration;
2, rescue car in the validity period of the drug, the quality of the qualified, a variety of items in the expiration date;
3, all kinds of equipment is intact, in an emergency situation, the oxygen bag gas volume is sufficient;
4, All first aid medicines and articles are replenished in time after use;
5. The handover register of the rescue car has no missing items, and the head nurse checks once a week;
6. The administrator of the rescue car organizes regular training for the use of medicines in the rescue car, and their effects and side effects;
7. Instruments and equipments are placed in different categories, and they are cleaned and neatly, and are managed by numbers.
8, instrument and equipment administrators regularly organize training in the use of instruments and equipment;
9, instrument and equipment failures have emergency plans and measures to achieve full knowledge;
Daily A5 nurses on duty on the resuscitation trolleys, life-supporting instruments to check the registration, the quality control officer at least once a month to regularly check the emergency medicine and equipment, to avoid expired drugs and damage to emergency equipment, to ensure that emergency equipment and medicines are used in the emergency department.
(E) quality nursing management group:
1, the head nurse scheduling reflects the ability to correspond to the realization of flexible scheduling, nurses know the human resources flexible deployment program;
2, the implementation of the bed responsibility system and bedside work system, the responsibility of the class in charge of a certain number of patients, the implementation of holistic care;
3, the ward environment is neat and quiet, such as found in the timely rectification of the problem;
3, the ward environment is clean and quiet, such as found problems Rectification;
4, nursing staff dress code, civilized language, warm reception of patients;
5, nurses know the connotation and goals of quality care;
6, the department to provide convenient service measures, such as: disposable cups of water, paper towels, needle and thread box, microwave ovens, etc.;
7, basic care:
(1) morning care requirements to achieve bed unit neat and tidy, bedside table items neat, stool positioning neat, by the responsible nurse;
(2) drainage tube placed reasonably, fixed correctly, all kinds of catheter fluids, observation records and meet the requirements, every Tuesday and Saturday replacement, comply with the principle of aseptic operation;
(3) oral care to make the patient's mouth clean, moist, maintain the integrity of the oral mucosa, daily1
(4) responsible nurses do patients everyone three short (finger, nail, beard short), six clean (hair, mouth, skin, perineum, fingers and toes, bed), bedside monitor hierarchical care, diet and medical advice in line with the nursing staff to know the patient's dietary requirements, to assist the patient to eat;
(5) the head nurse from time to time to check the quality of life quality of care;
(6) skin, oral mucosa, drainage tubes, etc., carefully do a good job of handover, defects occurring due to unclear handover, the responsibility of the nurse who takes over;
8, specialty care:
(1) organization and training of nursing routines for diseases in the department, according to the routine of the patient's nursing care;
(2) the nurse-in-charge of the patient to know the "ten know";
(3) Responsible nurses timely and accurate assessment of various risks to patients and tracking;
(4) According to the different stages of the patient's condition to be able to carry out health education for patients;
QC joint doctors every month, organizing patients to carry out the public holiday symposium, and make good meeting records. Weekly completion of quality care inspection content, the end of each month to do a good job of data summary, summarize the problems, analyze the reasons and put forward corrective measures.
(F) Nursing training group:
1, nurses know their respective job responsibilities;
2, in accordance with the training plan for each level, the organization of learning and training related content;
3, each level of nurses have their own tutor to guide, learning;
4, the organization of the monthly business learning two times, the trainer to do a good job of
T to carry out Lecture;
5, monthly organization of 1 nursing saki room or case discussion;
6, operation assessment:
(1) according to the operation plan to complete the operation training, monthly timed demonstration of basic and specialty operations by the operator;
(2) operator demonstration, the head of the nursing staff and the operator to conduct a spot check examination;
(3) according to the characteristics of this section (3) According to the characteristics of the first aid skills training and assessment of 1-2 times;
(4) give full play to the enthusiasm and potential of each nurse to enhance the ability of nursing operations;
Quality Control Work Planner (Part 3)I. Goal: Basic nursing care pass rate ≧ 100%, first-level nursing care pass rate ≧ 90%, the critical care of patients with a pass rate of ≧ 90%
Implementation measures:
1, the nursing quality management committee quarterly on the hospital wards, ICU, CCU, etc. to carry out a comprehensive quality assessment and inspection, timely feedback in the regular meeting of the head of nurses to analyze and evaluate and improve.
2, the head nurse daily inspection, found that the problem is resolved in a timely manner.
Second, the goal: the number of nursing errors occurred in the year ≦ 0.5 hundred beds
Implementation measures:
1, often emphasized in the regular meeting of the head of nurses, to strengthen the nursing safety education, to improve the safety awareness.
2, the department has a safety prevention education program and measures, the head nurse is responsible for the implementation.
3, the department occurred. Errors, defects should be reported, discussed, and handled in a timely manner, and monthly statements on time.
4, nursing error and accident management committee regularly on the hospital's nursing defects, errors and accidents to analyze, identify, and put forward improvement measures.
Third, the goal: first aid items intact rate of 100%, first aid facilities intact rate of 100%
Implementation measures:
1, first aid medicines, items of each class serious handover, after use in a timely manner to replenish, to achieve the "four fixed".
2, the department is responsible for, check twice a week, the head nurse weekly check, sign.
3, the nursing department quarterly inspection, assessment.
Fourth, the goal: the annual number of bedsores 0 (except in special circumstances)
Implementation measures:
1, strengthen the care of serious patients, bedridden patients to establish turnover card, bedside handover records.
2, the head nurse daily supervision and inspection.
3, the nursing department random inspection.
Fifth, the goal: nursing technical operation qualification rate of 100%, disinfection and isolation qualification rate of 100%, the recovery rate of disposable medical items 100%
Implementation measures:
1, the strict implementation of a person, a needle, a tube and a bandage, a bed, a towel, a table, a cloth.
2, strict distinction between clean and contaminated areas of the treatment room and dressing room.
3, strengthen the three basic training, nursing technical operation standardization.
4, the nursing department regular inspection, assessment.
5, regularly do a good job of monitoring the work, to prevent intra-hospital cross-infection.
6, the strict implementation of the classification of disposable medical articles collection, unified storage and processing.
Sixth, the goal: admission assessment and patient status compliance rate ≧ 80%, nursing diagnosis of problems with the rate of ≧ 90%
Implementation measures:
1, the requirements of the collection of information is comprehensive, timely and accurate, in line with the patient's condition.
2, each department lists the nursing diagnosis of common diseases for nurses to learn, master and use.
3, the nursing department, the head nurse according to the patient's condition, ask the nurse in charge, check the nursing charts, records and so on.
4, check the nursing problem, assess the accuracy of the patient's condition with the patient, and timely guidance and correction.
VII. Goal: 100% implementation rate of the nursing program, with an evaluation of the effect
Implementation measures:
1, the development of specific, timely, effective and scientific nursing measures to facilitate the operation of the nurse.
2, guiding the head nurse to master the nursing measures in line with the patient's problems.
3, require nurses to timely effect evaluation.
4, the nursing department, the head nurse supervision and inspection.