Medical quality and safety work summary 4

Medical quality and safety work summary 1

A practical improvement of medical services

Strengthen medical ethics and medical laws and regulations, rules and regulations education, so that the majority of staff to further establish the wholeheartedly for the patient service idea, adhere to the "patient-centered" service concept, seriously carry out the content of "good service, good quality, good medical ethics, the masses are satisfied" "three good, good quality, good, the masses are satisfied". "Patient-centered" service concept, and seriously carry out the content of "good service, good quality, good medical ethics, public satisfaction" of the "three good and one satisfied" activities, and constantly improve the level of medical services. service level. Innovative service process, optimize the diagnosis and treatment environment. We have enriched outpatient physicians, rationalized working hours, and insisted on opening clinics on time to ensure that patients are seen in a timely manner. The establishment of an open and transparent system of medical expenses, the implementation of a one-day list system for hospitalized patients, patients can always query the price of drugs, hospitalization costs and other details, by the patient's praise.

Strengthen doctor-patient communication, improve the content of communication, improve communication, focus on the effect of communication, and effectively strengthen the basic management of the hospital, the establishment of a sound medical safety management organization, the implementation of the core medical work system and safety measures, to ensure that medical instruments and equipment are legal, reasonable, and safe to use, to avoid the occurrence of medical errors and accidents. Strict technical access system, standardize medical practice behavior. Seriously implement the "Drug Administration Law", "Medical Devices Supervision and Administration Regulations", and strengthen the supervision and management of the purchase, storage and use of drugs and medical devices.

Second, effectively improve the quality of medical services

Medical quality and safety is related to the public's health and safety, is the lifeline of medical services, is the core content of hospital management and eternal theme. The first step in medical safety is to improve the quality of medical care and enhance the level of service. Strengthen the medical quality management, pay close attention to the implementation of rules and regulations, always adhere to the "patient-centered", quality as the core, quality and safety as the theme, seriously implement the rules and regulations, job responsibilities, strict implementation of diagnosis and treatment technology routines, the implementation of the various systems in all aspects.

The establishment of xx town health hospital medical quality management group, strengthen the quality management of medical documents, strict implementation of the "basic norms of medical record writing", the quality of the case implementation of the whole monitoring and management. The development of xx town health hospital professional and technical personnel assessment program, in order to implement the reward and punishment mechanism, to ensure that the rewards and punishments in place, the quality of medical services assessment of the outstanding results of the department or individual to give praise and material incentives; the quality of medical services assessment of the results of substandard department or individual in addition to financial penalties and hospital-wide notification of the criticism, to strengthen the "three basics and three strict" training, held from time to time at all levels and types of personnel. The three basic training, held from time to time at all levels and types of personnel three basic assessment of the level of clinical theoretical knowledge of medical personnel and practical skills for a comprehensive assessment, and the results of the assessment and personal assessment linked to ensure that the quality of medical and technical personnel of their own technical qualities continue to improve and update, and comprehensively improve the quality of medical personnel business.

Third, the establishment of a perfect quality management system, standardize medical behavior is the core

This year, our hospital from the strengthening of the system construction, combined with the nature of the work of the job, the work of the content, the development of the relevant management system and assessment rules, and the development of functional departments, business departments, the comprehensive objectives of the responsibility to achieve the first level of management level, the first level of responsibility to the first level of the pattern. Clearly responsible for ensuring that the function, so that the responsibility, the right to clear, moderate interest, so that the management of the chapter to follow, the chapter must follow, and gradually improve the management of the legal system, institutionalization, standardization, standardization.

Fourth, in accordance with the law to properly dispose of disputes between doctors and patients

According to the relevant laws and regulations, the disposal of disputes between doctors and patients into the legal system, standardized track, to safeguard the legitimate rights and interests of doctors and patients. According to the "Regulations on the Treatment of Medical Accidents" set up xx Township Health Center medical dispute coordination and handling group, according to law properly deal with the doctor-patient disputes. Adhere to the principle of prevention in the first, found in the early, disposed of in the small, establish and improve the prevention and disposal of disputes between doctors and patients mechanism, the careful implementation of relevant preventive and control measures, and strive to resolve all types of disputes between doctors and patients, to prevent disputes between doctors and patients caused by mass incidents and vicious incidents.

V. Strengthen security measures to ensure the safety of the hospital

Regularly organize key positions for staff to learn and train, the implementation of various internal security measures. Regular and irregular fire safety to carry out a comprehensive inspection, easy to cause fire, storage of dangerous goods and the concentration of people in the place of key inspections (such as the drugstore, outpatient clinics, wards, etc.), the regular maintenance of fire safety facilities replacement, to ensure that the fire fighting equipment in good condition. Our hospital implements the general duty system of hospital leaders, clearly defines each person's time period division of labor, and conducts hospital-wide inspections during the duty period, so as to effectively implement the security precautionary measures of fire prevention, anti-theft, and anti-sabotage into practice. Strictly implement the security responsibility system, to improve the destabilizing factors investigation, found that the problem is immediately rectified. The development of human defense, material defense, technical defense emergency measures to ensure that the hospital does not appear major security incidents.

Medical quality and safety work summary2

20xx year is our xx city xxxx hospital to create an important year of the third-class hospital. During the year, we have a comprehensive, new, more profound understanding of the understanding and experience of medical quality and safety, summarize the Department of Neurology in 20xx medical quality and safety work as follows:

First, we in the beginning of 20xx that is, in January and February developed a work plan, the focus of the work from January to December 20xx have a co-ordination of the work of the overall arrangements for the implementation of the work of the specific work of the person, the responsibility of the person, the implementation of all the work of the work of the person, the responsibility of the person, the implementation of all the work of the work of the person We have made a work plan at the beginning of 20xx, that is, January and February, and made a comprehensive arrangement for the work priorities from January to December 20xx. Under the leadership of the relevant functional departments of the hospital, we have continued to learn and improve the doctor-patient communication system (including the first communication after admission, pre-discharge communication between doctors and patients, and communication at any time of the change of the condition), assess the condition of patients hospitalized for more than 30 days, formulate the Neurology Clinical Diagnostic and Treatment Guidelines, operational standards, operational procedures, improve the Department of Pharmacology management (especially for the management of antimicrobials), the supervision of multi-drug resistance

Second, the implementation of quality control of medical records. Before 20xx, the supervision of the quality of medical cases in my department is mainly for regular or irregular random inspection of medical records, in the shelves of medical records, the results of the inspection is recorded in the quality of medical records self-check registry, found that the problem in the morning meeting, in order to achieve the improvement of the *** with the improvement of the 20xx, we were based on the medical department respectively issued a new quality of inpatient medical record scoring standards for the quality of the department of the case scoring. During the year, *** sampled more than 100 in-shelf medical records, with no grade B or C records. ****Checked 577 archived medical records from January to June 20xx, and found that the third-level physician checking system was implemented, but the implementation was not in place, there were scribbles in the medical records, the communication between doctors and patients was not signed, and the quality of the writing of medical records was not high. Such as changes in the development of the condition, prognosis, differential diagnosis is too little **** sexual problems, and in July 20xx after the gradual rectification.

Third, the supervision of antimicrobial drugs. According to the situation of our department, in order to achieve the relevant objectives issued by the hospital, we strictly implement the hierarchical management of antimicrobial drugs, and repeatedly organized the department to study and assess the strict implementation of the use of antimicrobials in the application of the Department of the hospital to successfully complete the objectives of the hospital that is the intensity of the use of antimicrobials in the 20DDD below. Over the past year, the intensity of antimicrobial use in our department has been 9-12DDD, and the standardization and process of using antimicrobials at the restricted level have been strictly implemented. The use of special grade antimicrobials are selected according to the results of drug sensitivity, and apply for a consultation organized by the pharmacy department before use. However, due to the lack of understanding of this work, there was one case in which no consultation was requested and the drug was selected based on the drug sensitivity results only. During the year, the inpatient department of neurology registered the use of antimicrobial drugs (including dosage, dosage form, and usage) in discharged patients. The total number of outpatients using antimicrobials was counted daily, and less than 20% of outpatients used antimicrobials.

The above work exists in the use of antimicrobial drugs before the failure to send microbiological examination in a timely manner, analyze the reason is mainly due to the presence of infections in patients after admission to the hospital, send the examination may affect and delay the diagnosis and treatment of patients.

Fourth, the implementation of the three basic three strict training. Since July 20xx since the development of the three basic three strict training program, the development of training standards, and training in the department of unarmed cardiopulmonary resuscitation process, lumbar puncture process, physical examination of the scoring standards.

Fifth, single disease and clinical pathway quality control work. So far my department *** have acute cerebral infarction, viral encephalitis, epilepsy persistent state of three kinds of diseases into the single disease and clinical pathway management. Summarizing 20xx, our department **** has 91 cases of acute cerebral infarction, enrolled in single disease management, with an average hospitalization cost of 14,100 yuan and an average number of hospital days of 14.2 days. Viral encephalitis 7 patients were enrolled in clinical pathway management and 0 cases of persistent status epilepticus. To summarize the above data, the persistent status epilepticus and viral encephalitis were enrolled in fewer cases. The small number of single disease network direct reporting is caused by the fact that the computer in our department was installed only in March and our physicians did not pay enough attention to the network direct reporting.

Sixth, the teaching work quality control summary. 20xx my department *** receive interns 72 people, including general practitioner transfer training 4 people, xx medical college 2 people, xx medical school 1 people, xx Chinese medicine college 34 people, xx medical college 31 people. *** Organized 16 lectures in the department on neurological physical examination, anatomy of the nervous system, diagnosis and treatment of cerebral hemorrhage, cerebral infarction, subarachnoid hemorrhage and epilepsy.

VII, hand hygiene, nosocomial sensation, multi-drug resistance work summary. 20xx since June, the department to carry out and participate in the hospital on hand hygiene, nosocomial sensation, multi-drug resistance of the relevant knowledge of the training for a number of times, so far, has been in the department of self-examination of a hand hygiene and related knowledge, multi-drug resistance of the assessment has reached the standard.

eight, blood transfusion system of learning, implementation. 20xx year I seriously organized to participate in the hospital blood transfusion knowledge training, section *** with the study of nearly 10 times, serious study of the indications for blood transfusion, seriously complete the blood transfusion application form, blood transfusion before and after the assessment and blood transfusion of the implementation of the doctor's orders. 20xx year I *** there are two patients transfusion of autologous blood, self-checked transfusion medical records scored in 90 points. The patient's blood transfusion medical record score was above 90 points after self-examination.

IX, the implementation of the system of internal discussion. My department has always insisted on difficult medical record discussion, critical case discussion, death case discussion, this year, the establishment and improvement of hospitalization more than 30 days assessment and discussion system. 20xx year my department **** there is a death case, the department organized discussions and records. Difficult cases were discussed five times, one critical case was discussed, and 70 patients were hospitalized for more than 30 days, which were written and recorded in a timely manner in strict accordance with the case discussion system. Which fill out the hospitalization more than 30 days statement 10.

Ten, the implementation of critical value reporting system. Since May 20xx, **** receive critical value report 36 times, by the hospital and departmental self-check, July 22, 20xx missed a registration, the critical value of the patient Li Huaxiang (236417) blood culture detected G + positive bacteria, has been in the department for learning, and the parties involved in the punishment, has been formulated to rectify the measures.

XI, the establishment and improvement of multi-drug-resistant bacteria (category II) register and related systems. Hospitalized patients transfer register *** transferred to 51 patients (since June 21, 20xx began to register). 20xx I *** reported multi-drug-resistant bacteria (Class II) 1 case, for sputum culture detected Klebsiella, has taken bedside isolation, special instruments, strict hand hygiene and other appropriate measures. At present, the patient was admitted to the hospital.

XII, the establishment and improvement of unplanned admission and re-entry registration and assessment system. Since May 20xx, **** there are two cases of unplanned return, Zhao Guoshu (245318) diagnosis of cerebral infarction recovery, 8 days after discharge to return to the return, return to the reason for the patient hopes that the limb function recovery is better, vascular disease did not reoccur. Xiao Huaixue diagnosed intracranial multiple occupying lesions (brain metastases?). The patient went to xx diagnosis and treatment, but the higher departments have no beds and therefore returned.

XIII, improve the patient discharge follow-up system and further implementation. Among them, more than 70 cases of follow-up by nursing staff, 15 cases of follow-up patients by doctors, at present, the number of cases of follow-up by physicians in my department is relatively small, analyzing the reasons are: lack of awareness of follow-up, part of the follow-up patients have omitted to register the situation. At present, my department has configured a public cell phone to further strengthen and implement the follow-up system for discharged patients.

Fourteen, improve the adverse event reporting system. 20xx I **** reported 14 cases of adverse events, of which 1 case of water and electricity adverse events, wall contamination 1 case, 3 cases of nursing adverse events, 9 cases of adverse drug events, analyze the reasons are: high-risk patients fell out of bed, fall events. Adverse drug events involving drugs: carbamazepine, ampicillin, amoxicillin flucloxacillin, cefmetazole, etc., analyzed mainly for the side effects of drugs, the main symptoms occurring are: rash, itchy skin, digestive adverse reactions, after stopping the drug to give anti-allergy treatment are cured.

XV, the development and improvement of complaints and management mechanism. 20xx year I **** 2 cases of patient complaints, 20xx September 4, patient xxx family complaints discharged from the hospital with the needle water error, my department to take the implementation of self-checking, reported to the Department of Nursing and the Medical Department. After the implementation of the situation on the parties involved in the criticism and education and punishment. 20xx October 7, patient xxx complained of unsatisfactory blood pressure control, cerebral infarction foci have not disappeared, cough did not get better, the department to organize the whole group of physicians checkup, analysis of the reasons for the adjustment of the treatment plan, and to explain to the patient infarction foci can not be disappeared, please respiratory xxx director of the consulting to help diagnose respiratory lesions, the patient was discharged after the improvement.

Summarizing the above, we work in 20xx, the number of beds increased significantly, the workload increased in the case of medical quality control in the hospital under the leadership of the leadership of the hospital leadership and the relevant departments, through the **** with the efforts of all health care workers, did a lot of work. However, to summarize, there are many aspects of the implementation is not in place, there are many details are still lacking, such as the core system of knowledge and the implementation of the relevant systems still need to make further efforts, the next year, we strive to follow up on discharged patients single disease management, hand hygiene, medical advice review, case quality supervision to do more work, and strive to make the quality of medical care of my department to a higher level.

Medical quality and safety work summary 3

20xx, according to the hospital medical quality and medical safety management committee work plan, developed a number of goals, and one by one implementation. However, there are still many shortcomings, in the future work still need to continue to improve and perfect, now the 20xx medical quality and medical safety management work is summarized as follows:

First, according to the law practice management

In order to further strengthen the implementation of the implementation of the practice of law and the implementation of the safeguard of medical safety, the medical department to strengthen the hospital's practice of law to inspect, supervise, implement, feedback, organization of learning and The medical department strengthens the inspection, supervision, implementation, feedback, organization of learning and implementation of the whole hospital. The company's management of the practice, requiring the director of each section to strictly control the entry, without the license must be practiced under the guidance of a licensed physician.

Second, the construction of the system, continue to improve the system

In the implementation of the various medical regulations and operating standards at the same time, the hospital revised the medical, pharmaceutical, technical management standards and clinical specialties.

Third, regular medical quality inspection, continuous improvement of medical quality: the Medical Department of the hospital's clinical departments to carry out quality checks. Strictly in accordance with the requirements of the "Basic Standard for Medical Record Writing", the organization at least once a month to supervise and inspect the quality of medical records.

Fourth, the main deficiencies

1, the quality of medical care:

(1) the quality of medical documents in some departments is poor: mainly in the superior physician check-up records are exactly the same, the routine inspection is not perfect, there are many logical errors in the medical record (such as the patient's name, gender, age, inconsistent diagnosis of entry and exit, etc.), the results of the important abnormal examination without analysis, no records, diagnostic basis is insufficient, some physicians or the hospital.

(2) The use of antibiotics in some departments is not standardized

(3) The work of the medical quality control team in some departments has not been put into practice.

Fifth, the next stage of medical quality and medical safety management work focus:

1, to strengthen the study of laws and regulations, strengthen the supervision, and strictly good access to practice, so that medical personnel at all levels consciously practicing law, according to law.

2, to strengthen the study of various types of quality management system, to improve the quality of medical care, so that the diagnosis of the standard, the treatment has a basis.

3, do a good job in the "basic specification for medical record writing" (20xx version) training, improve the quality of medical record writing. Strengthen the "three basic and three strict", and constantly improve the quality of medical staff and practice level, and continuously improve the quality of medical services.

4, improve and unify the hospital medical quality evaluation standards.

5, to further improve the hospital and departmental management organization, the implementation of hospital and departmental medical quality management system and responsibility.

6, the current operation of the medical records by the Medical Department to organize regular inspection; archived cases by the Medical Department and the case room to organize the relevant department director or quality control physicians regularly or irregularly supervise the inspection of medical records, at least once a month.

Medical quality and safety work summary 4

The ultimate goal of health care reform is to provide patients with better quality medical services at a lower cost. In recent years, our hospital, like other municipal general hospitals, has become a basic part of the city's health care work, and has formed a unique system of maternal and child health care work, and has made unremitting efforts to provide women and children throughout the region with high-quality and inexpensive medicine and health care services, inheritance of the development of medical science and medicine and training of medical personnel. In 20xx, our hospital adhere to the patient-centered service concept to improve the quality of care, reasonable fees, reduce medical costs as the starting point, and strive to provide quality medical services for the majority of patients.

First, strengthen the quality of medical management, to ensure and improve the quality of medical services

(a) Medical quality management is the core of hospital management, to improve the quality of medical care is the management of the fundamental purpose of the hospital. Medical quality is the lifeline of the hospital, the level of medical care, medical quality is directly related to the survival and development of the hospital. In recent years, on the basis of medical quality service, our hospital has taken reducing medical quality defects, timely investigation and elimination of medical safety hazards, reducing medical malpractice disputes and eliminating medical accidents as the top priority. Our hospital strictly controls the medical quality, each department strictly implements the rules and regulations, standardizes the diagnosis and treatment behaviors, and insists on the system of first diagnosis and responsibility, the system of three-stage check-up, consultation of difficult patients, and the system of discussing the critically ill patients and the pre-operative and post-operative procedures. Enhance the sense of responsibility, pay attention to the dynamic analysis of medical activities, and take all kinds of precautionary measures, so as to prevent the problem before it occurs. In order to improve the current demand for patients' right to medical information, improve the various notification systems.

Strengthen the quality control management.

(B) optimize the medical service process to improve the basis of medical quality. The service process is the structure and mode of operation of the medical institution. On the basis of not increasing the number of wards and health and technical personnel, the optimized medical service process determines the efficiency and competitiveness of the medical institution, which enhances the long-term viability of the hospital to a large extent, so that the available resources of the hospital can reduce duplication and waste by balancing the components of the process, and so that the existing hardware and software of the hospital can achieve a higher utilization rate and better utilization level, give full play to the abilities of professional and technical staff as much as possible, meet the needs of patients as much as possible, and achieve high economic and social benefits. Our hospital adheres to the patient-centered approach, makes efforts to optimize the medical process, facilitates patients' access to medical treatment, seeks for practical effects, enhances the service consciousness, optimizes the development environment, and strives to provide patients with warm and convenient, high-quality medical services. The introduction of various measures to facilitate the people, such as charging the registration window networking, to reduce the long queues for registration, some experts set up a special registration window, the introduction of telephone booking registration and other measures. The medical and technical departments have introduced time-limited commitments for the issuance of report forms. Nursing department in the implementation of star nurses selection activities emerged a number of advanced nurses, nurses and patients to build a bridge, the introduction of convenient measures to find ways to solve practical problems for patients, hospitalized patients on the nursing work satisfaction rate of 98%.

(C) the implementation of medical quality, medical safety education, is to strengthen the foundation of medical quality. How to improve the quality of the managers themselves and strengthen the quality of the whole hospital medical staff education is the basis of quality management. Improvement of medical quality can not be achieved solely by the efforts of a few managers or some of the medical staff, but the need for all hospital workers have a correct outlook on life, values, professional ethics; the need for a strong sense of responsibility, professionalism, compassion; the need to set up a solid awareness of the quality of medical care, medical safety; in the hospital to carry out a full range of high-quality service and "safety"




Safety is the biggest savings, accidents are the biggest problems. The hospital comprehensively carry out quality service and "safety is the biggest savings, accidents are the biggest waste" activities, stimulate the staff than learning, dedication to the spirit of professionalism, the formation of a better than, learn, catch up with, and surpass the good atmosphere.