Objective 1:Strict implementation of the checking system to improve the accuracy of patient identification by medical staff.
1. Further implement the checking system for all diagnostic and therapeutic activities, and use at least two methods of patient identification at the same time when drawing blood, administering medication, or giving blood transfusions, and shall not use only the room number as the basis for identification. Carry out the method of asking patients to say their names and then checking again to confirm the patient's name.
2, in the implementation of any intervention or invasive high-risk diagnostic and therapeutic activities before the responsible person should take the initiative to communicate with the patient or family members as a means of final confirmation to ensure that the correct patient, the implementation of the correct operation.
3, improve the key process identification measures, that is, in the key process, are patient identification of accurate specific measures, handover procedures and record documents.
4, the establishment of the use of "wristbands" as an identification system, the use of "wristbands" in the diagnostic and therapeutic activities, as a means of identifying patients before the various diagnostic and therapeutic operations.
Objective 2: Strictly implement procedures for effective communication between medical staff in special cases, and implement medical instructions correctly.
1. Correctly execute medical orders without using verbal or point-of-call instructions.
2. Only in the emergency rescue of critically ill patients in special circumstances, the physician issued a verbal temporary medical advice, the nurse should be repeated to the doctor, in the implementation of the implementation of double check.
3. Receive verbal or telephone notification of the patient's "critical value" or other important test results, the receiver must be standardized, complete records of test results and the name and phone number of the reporter, for review to confirm that there is no error before providing the physician to use.
Objective 3:Strictly implement the surgical safety verification system and process to prevent errors in surgical patients, surgical sites and procedures.
1Establish and implement a pre-operative verification system and process with a handover verification form to confirm that documents and items necessary for surgery (e.g., medical records, photographic materials, special intraoperative medications, etc.) are ready.
2The establishment of a pre-operative immediate stop system and standardization of preoperative marking of the surgical site by the surgeon, and the initiative to invite the patient to participate in the identification, to avoid the wrong site, the wrong patient, and the wrong operation.
Objective 4:Strictly enforce hand hygiene norms and implement the basic requirements of hospital infection control.
1Develop and implement a hand hygiene management system for healthcare workers and hand hygiene implementation specifications, and cultivate effective and convenient hand hygiene equipment and facilities. Provide necessary safeguards for the implementation of hand hygiene.
2Develop and implement the norms for the use of sterile medical devices during surgical operations by healthcare workers, and post-surgical waste should follow the basic requirements of hospital infection control.
Objective 5:Improve medication safety.
1, the establishment of ward medicine cabinet in the drug storage, use, limits, regular inspection of the standardized system; storage of poisonous, dramatic, narcotic drugs have management and registration system, in line with regulatory requirements.
2. There are norms for storing high-risk medicines in wards, and they are not allowed to be mixed with other medicines; high-concentration electrolyte preparations (including potassium chloride, potassium phosphide and more than 0.9% potassium chloride, etc.), muscle relaxants and cytotoxicity, and other high-risk medicines have to be stored separately, with eye-catching signs.
3, the ward medicine cabinet of injectable drugs, internal drugs and external drugs are strictly separated from the placement of sterile items are strictly classified and stored, infusion disposal supplies standby items, skin disinfectants and air disinfectants, items of disinfectants are strictly classified into separate rooms for storage and management.
4, all prescriptions or medication doctor's orders in the transcription and implementation, there are strict two-person checking, signature procedures, carefully followed.
5, in order to give and implement the injection of medical advice (or prescription) to pay attention to drug contraindications.
6, the ward to establish key drugs after the drug observation system and procedures, physicians, nurse practitioners must know these observation system and procedures, and can be implemented. For new special drugs to establish a pre-medication learning system.
7, the pharmacist should provide outpatients with rational use of drugs and the method of medication adverse reaction service guidance.
8, to further improve the infusion safety management system, strict contraindications of drugs, control the flow rate of intravenous infusion, the implementation of the maximum number of drops of infusion patients limited to inform the procedure to prevent infusion reactions.
Objective six: to establish a clinical laboratory "critical value" reporting system.
1. "Critical value" items should at least include: blood calcium, potassium, blood glucose, blood gas, platelet count, white blood cell count, prothrombin time, activated partial thromboplastin time, and so on.
2. "Critical value" report focuses on the emergency department, operating room, all kinds of intensive care unit and other departments of the emergency, critical patients.
3. "Critical value" of the report of the project to implement strict quality control, especially pre-analytical quality control measures, such as specimens should be collected, storage, transportation, handover, processing regulations.
Objective 7: Prevent and minimize patient falls.
1. For patients undergoing physical examination, surgery, and undergoing various examinations and treatments, especially children, the elderly, pregnant women, and patients with limited mobility and disabilities, prevent the occurrence of patient falls by using verbal reminders, assisting, asking for help, or warning signs.
2. Implement the fall prevention system carefully and establish the fall reporting and injury recognition system.3 Do a good job of basic nursing care, to allocate and use nursing human resources, open beds and wards, the ratio of nurses on duty 1;0.4. If the manpower is equipped with insufficient manpower, managers should be carried out in a timely manner, the manpower crisis value of the reporting system.
Objective 8:Prevent and reduce the occurrence of pressure ulcers in patients.
1. Effective pressure ulcer prevention systems and measures are carefully implemented.
2. To implement measures to standardize the treatment and care of pressure ulcers.
Objective 9: Proactive reporting of medical safety (adverse) events. Medical adverse time reporting is useful for detecting adverse factors, preventing medical errors, ensuring medical safety, promoting medical development and protecting patients' interests; it can effectively avoid medical defects; it can increase the transparency of medical standards and services.
1Hospitals should advocate proactive reporting of adverse events. There are mechanisms to encourage medical staff to report.
2 Actively participate in the voluntary, non-punitive adverse event reporting system of the China Hospital Association to provide information on medical safety for the industry.
3 Form a favorable healthcare safety culture that promotes a non-punitive, non-personalized environment, and has incentives for staff to actively report adverse events that threaten patient safety.
4 hospitals are able to combine safety information with the actual situation in the hospital, from the hospital management system, from the operating mechanism, from the rules and regulations of targeted continuous improvement, hospitals have at least two pieces of systematic improvement programs each year.
Goal 10:Encourage patient participation in healthcare safety.
1.Proactively invite patients to participate in healthcare safety management, especially patients are informed of the purpose and risks before undergoing surgical, interventional, or invasive procedures, and are invited to participate in the identification of the surgical site.
2. When medication is administered, patients are informed of the purpose of the medication and possible adverse effects, and are invited to participate in the checking of the medication.
3. Inform patients of the importance of providing true information about their condition.
4. The nurse should inform how to cooperate and the importance of cooperating with treatment when performing nursing and psychological services.