Medical safety refers to the implementation of health care in hospitals, the patient does not occur outside the scope of the laws and regulations allow psychological, organic structure or function damage, impairment, defects or death. Its core is the quality of medical care. Medical safety and medical effect is a cause and effect relationship, medical safety directly affects the social and economic benefits.
Medical safety hidden danger self-inspection report sample:According to the XXX Health Bureau on the development of ? The three good and one satisfied? activities of medical quality and safety rectification activities, our hospital has carried out a comprehensive inspection of key departments and key sectors. Now on the results of self-examination and corrective measures reported as follows:
First, there are problems:
(a) some medical management system and the implementation of the implementation is not in place
Individual medical staff medical quality and safety awareness is not high enough, on the first physician responsibility system, checking the system, the case discussion system, the system of consultation, the referral system, transfer system and other core systems can not be well implemented. The core system can not be well implemented.
(2) the application of antibacterial drugs still exists unreasonable phenomenon
Individual medical personnel antibacterial drug use is unreasonable, such as the common cold also use antibiotics; perioperative prophylaxis is unreasonable, antibiotic use time is too long.
(C) hospitalized medical records writing problems still exist.
1, handwriting scribbles, there are scribbles, name, hospitalization number does not match and so on.
2, the course of the record of the modified medical advice, positive laboratory results lack of analysis, the content of the record of the examination of less analysis, too formalized.
3, the existence of informed consent to inform, the signature is not standardized, drugs and disposable high and low value consumables and other self-funded items are not signed informed consent.
Second, 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 belittle the learning of quality management knowledge, quality management knowledge is lacking, quality awareness is not strong, so that can not consciously and actively apply the quality requirements in 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 medical related laws, regulations, rules and regulations. Medical staff must master the relevant laws and regulations, the core system of medical quality, and improve the quality consciousness of medical staff, safety consciousness and preventive consciousness.
(2) Increase supervision and inspection efforts to ensure the implementation of the core system.
1, to further strengthen the quality of the room and running medical records inspection work, focus on the effectiveness, not a formality, on the problems found in addition to face to face explanation, the repeated offenders must be punished through financial penalties, to give discipline.
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.
3, to strengthen the management of case quality.
In the hospital to carry out standardized training in medical record writing, and further improve the relevant system and medical record inspection standards, to ensure the timely filing and safe flow of hospitalized medical records.
4, to further strengthen the monitoring of hospital infection.
Strictly implement the hospital infection management system. 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 link to play the role of the Hospital Infection Management Committee, and actively work to eliminate the underreporting of hospital infection events.
5, to further strengthen the management of the use of antibacterial drugs.
According to the "forwarding on the issuance of Guangdong Province on the clinical application of antimicrobial drugs management guidance" the spirit of the document, the establishment of the hospital "antimicrobial drug clinical use management group" organization, strictly carry out the management of antimicrobial drug clinical use, focusing on monitoring the perioperative prevention of drug use. Further implementation of antimicrobial drug hierarchical management system, set prescription authority, to ensure the implementation of the system, improve bacterial culture, drug sensitivity test rate, to ensure the rational use of antimicrobial drugs.
(3) Further strengthen the professional ethics education, and effectively improve the service level of medical staff.
According to the requirements of the Ministry of Health's "Code of Medical Ethics for Medical Personnel and Implementation Measures", medical ethics education for medical personnel. Cultivate modesty and prudence, not proud of the work style, aspire to be a medical ethics, respected by the people of the medical workers, and really set up? People-oriented, patient-centered? The concept of the patient as their loved ones, not for personal gain.
Medical safety hidden danger self-inspection report model two:I hospital according to the city health bureau issued on ? Medical safety hidden danger rectification? Activity requirements, seriously organize the majority of staff to learn the spirit of the activity, according to the requirements of the hospital in all aspects of the work of the special rectification activities. Through the rectification activities carried out since, now the hospital rectification problems and rectification measures reported as follows:
A. Problems:
(a). Problems in medical quality
1. Problems in the outpatient department
According to the management requirements of the outpatient emergency and clinic departments, our hospital outpatient emergency department is not set up separately, and there is no fixed outpatient and emergency staff with strong business skills. Outpatient and emergency doctors are not highly licensed, and there are cases of unlicensed and illegal practice of medicine. Some of the medical staff do not have high business skills, are not able to skillfully master and apply some common first-aid equipment, and are not skilled enough to master some basic first-aid techniques. The cooperation between the various departments is not close enough, and there is not enough collaboration between the departmental staff.
Medical instruments are not standardized. Outpatient prescription writing is not standardized, the elements are incomplete, the dosage and usage are not detailed, the application of antibiotics is not standardized, there is irrational use of drugs. Outpatient hospitalization medical records are too simple, not able to strictly regulate the writing of hospitalization cases. The quality management of hospitalized cases is not in place, and some medical personnel do not write cases in a standardized and timely manner. All kinds of records are not standardized, and the writing of records of conversation with emergency and critical patients, rescue records, records of discussion of difficult cases, and records of discussion of dead patients are not standardized, and the writing requirements are far from meeting the requirements of standardization of the quality of writing of medical documents. The registration of various outpatient logs is incomplete, discontinuous and incomplete. Some of the medical systems and core systems are incomplete and imperfect. To be with the further establishment, sound, the implementation of the relevant system of each department, especially the township hospitals continue to improve the core system of the implementation of the system is not in place, part of the system is not in line with the needs of the current stage of hospital management.
Problems in the Department of Nursing the nursing system is incomplete and imperfect. The previous nursing system is based on outpatient system management as a starting point for the establishment of up, since the inpatient building put into use, the original system has not been enough to adapt to the requirements of the current management, now need to be combined with the management of the inpatient department of the actual situation of the establishment of the relevant standard system.
Nursing management organization system is not complete. Not in accordance with the provisions of the Nursing Regulations system, the implementation of relevant nursing management, not the implementation of the target management responsibility system. Since the hospital inpatient department put into use since the nursing management department is not in accordance with the function and task of the township health center to establish a perfect nursing management system, the duties of each position is not clear, there is a mutual shirking of responsibilities in the work. Nursing human resource management is not complete, not combined with the actual establishment of the unit's nurse management system. There are no clear requirements for the qualification, technical ability and technical standards of nurses at all levels and in all categories, and they have failed to establish a sound mechanism for nurses' level and performance appraisal. According to the hospital nursing staffing standards, ward nurses and beds do not meet the required standards.
Nursing work assessment standard establishment is incomplete and imperfect. Regular assessment of nursing work is not timely, and is a mere formality. Not strictly in accordance with the "basic norms for case writing" writing nursing instruments, nursing instruments are not standardized, writing quality is not high. All kinds of registration is incomplete, such as disinfection records, detention records, emergency and critical patient rescue records, shift handover records, etc..
The concept of sterile technology is not strong, and the operation still needs to be further improved. Failure to effectively establish the nursing skills operation norms and standards, part of the nursing staff skills operation is not standardized, the destruction of disposable items is not thorough, not standardized. Outpatient clinics, inpatient departments and other departments of poor hygiene, there is a hidden danger of cross-infection, quilt covers, bed sheets are old, glass is not clean, cleaning is not timely.
2. Problems in the work of the pharmacy
Pharmacy drug management system is not complete. Poisonous, anesthetic, dramatic drug management system is not in place, the account records are not standardized, the management of hidden dangers. Drug management work is not in place, expired and invalid moth-eaten drugs still exist.
The hospital is actually engaged in the work of drug dispensing personnel are non-pharmacy professional and technical personnel, by other professional and technical personnel qualified by the Pharmacy and Inspection Bureau of the training to engage in the dispensing of pharmaceuticals. On the relevant drug dispensing drug knowledge is not enough to understand, prescription dispensing is not strict, from time to time there are unqualified prescription dispensing occurs. Part of the dispenser is not strong sense of responsibility, sometimes there is a mixing of the wrong drugs occur
(ii). Problems in the service attitude
The outpatient staff service attitude is not good, patients sometimes react, service attitude, service consciousness, poor service quality, medical services, there are cold, touch, hard, top and other problems, service attitude to be further improved.
Nursing staff service quality is not high, and fails to reflect the humanized service. Provide basic care and level of care measures are not in place, the care of hospitalized patients to stay in the primitive stage. Part of the medical staff medical service quality is not high, poor service attitude, patients reflect strongly. Some nurses are not responsible enough for their post duties, ? Three checks and seven pairs? system implementation is not in place, there are medical hazards. Nursing error reporting and management system is not in place, the observation of patients is not in place, the nurse is not able to take the initiative to report some nursing adverse events.
3. Pharmacy staff
Service attitude needs further improvement. Staff service awareness is poor, bad attitude, failed to establish a ? Patient-centered? The pharmacy management service model. To the patient service language cold, poor attitude, there is a quarrel with the patient, the patient reacted strongly. Service attitude needs to be further improved.
(iii). Cadres and workers work style, mental outlook problems
Part of the medical workers to get by, enterprising, sense of responsibility, initiative is not strong, need to further enhance the sense of responsibility for the work, a sense of urgency, a sense of crisis, to enhance the sense of service, to improve the way of service, improve the relationship between doctors and patients, so that the masses of people on the style of the health care institutions to significantly improve satisfaction. Part of the medical staff poor mental outlook, not wearing work clothes during the work period, do not wear a work permit, off duty, chatting, mental depression can not be able to work in a vigorous state of mind into the medical work.
(D). Problems in environmental health
For a long time the health care system, there is a health unit unhygienic situation, through the hospital inspection of the floor of each department, the glass is generally dirty, messy, poor situation, desktop items piled up, put, affecting the image of the health care unit.
Second, the rectification measures
1. To ensure the smooth progress of health rectification work to meet the requirements of the rectification program, the establishment of health work for the rectification of the leading group, responsible for the rectification of the hospital to provide a strong leadership guarantee mechanism.
Group leader Wang Gang is fully responsible for the health hospital and the village health center health rectification.
Members of the Li government is responsible for the rectification of health work in all relevant departments.
Wang Xiaoyi is responsible for the medical team and pharmacy to carry out strict rectification and report to the hospital office.
Zhang Lili is responsible for obstetrics and gynecology and maternal and child health care rectification
2. Strengthen the medical quality management, establish rules and regulations, pay close attention to the implementation, to eliminate medical accidents.
(1) the establishment of a long-term mechanism for the rectification of health care system. By the health care reform activities leading group responsible for medical quality and medical safety management, the establishment of a regular organization of personnel on the health care work management monitoring system, the hospital weekly organization of the relevant departments of the medical work of all departments of the personnel to carry out special inspections, the inspection of the existence of the problem registered in the health care inspector table, immediately put forward corrective measures, the responsibility of the person, the deadline for rectification and organization of the relevant personnel to carry out The situation of the rectification check.
(2) Establish and improve the relevant medical work management system. According to the requirements of the Health Bureau, the establishment of a sound system related to each department, especially the core system of continuous improvement of township hospitals, the establishment of a medical dispute prevention and disposal mechanism, timely and proper handling of medical disputes. The development of major medical safety events medical accident prevention plan and handling procedures, in accordance with the provisions of the report of major medical negligence and medical accidents, and effective prevention of accidental injuries caused by non-medical factors.
(3) establish and improve the supervision and assessment, reward and punishment system. The establishment of medical quality supervision and assessment system, the establishment and improvement of medical accidents, medical errors and medical quality analysis and deliberation meeting system, the quality of medical care and medical safety indicators, decomposition to the department and each person, the formation of medical safety everyone has a responsibility, there are indicators. In this hospital to establish a regular thematic study of health care and medical quality meeting system, in-depth discussion, analysis of health care health care work management problems. Problems in medical work and personal assessment linked.
(4) to strengthen the staff business skills training, improve the quality of medical services.
The improvement of hospital medical work is with the whole medical workers. Efforts strength is not open, so strengthen the comprehensive quality of medical workers in all aspects of training and improve is the premise, for this reason, our hospital will strengthen the comprehensive business quality of workers to improve as a breakthrough. According to the Health Bureau training requirements this year, plans to send four medical staff to the upper different levels of hospitals for more than half a year off-service training and learning. Through training, master the operation of common clinical skills, to provide patients with reasonable, simple and satisfactory medical services. In order to prevent learning in form, combined with the health center performance reward and punishment system will learn the effect and application in the clinic into the performance of the salary assessment, the real embodiment of fair competition, more work more, less work less performance appraisal system.
3. Improve the comprehensive quality of medical personnel and strengthen the construction of medical ethics.
Further strengthen the ideological education of the staff, seriously study the code of ethics for medical workers, the use of weekly Monday political learning and daily morning meeting time to strengthen the moral quality of medical staff training.
In response to the existence of some medical staff during the work of not wearing work clothes, not wearing a work permit, off duty, chatting, mental depression and other issues. Take strong measures to regulate the work behavior of medical staff, to ensure that the staff with a high working condition into the medical work.
In the service attitude rectification, to needle medical services in the existence of cold, touch, hard, top and other issues, grasp? The first time I saw this was when I was a student at the University of California.
In all medical staff to carry out civilized etiquette training, from the action, language, posture, expression and other aspects of the subtle aspects of intensive training, etiquette training results as a prerequisite for the staff to compete for jobs, a strict examination test, the full promotion of Putonghua in the medical staff to carry out a solid? Smile service,? Four Hearts (love, patience, care, responsibility) education, as the core content of the medical staff ideological and business quality education and professional ethics education, learning and education surface to reach more than 100%. Efforts to serve patients wholeheartedly, to establish the image of white Tianshi.
Strengthening management to strengthen hospital management, to solve the problems in the work style. To solve some of the staff work perfunctorily, catching the work of shallow, floating work style and the problem of work over the top, enterprising, sense of responsibility, initiative is not strong, so that the cadres and workers to further enhance the sense of responsibility for the work, a sense of urgency, a sense of crisis and awareness of the service, to improve the way of service, improve the relationship between doctors and patients, so that the masses of people on the style of health care institutions to significantly improve satisfaction.
Focus on changing the part of the head of the department of the old ideological concepts, conformism, ** eight stable, not thinking about progress, organization and management capacity is weak. To solve the part of the medical staff work without goals, no motivation, do the work of losing three or four, perfunctory, behind the back of the right and wrong, is not conducive to unity between comrades, spoil the good hospital atmosphere.
Strengthen the management to improve the quality of each person, and further strengthen the coordination between each person and each person, section and section, strengthen the unity of the workers, establish the concept of collectivism, and play a team spirit of solidarity. Set up the concept of scientific development, enhance the sense of innovation, carry forward the courage to dare to do the wind, with a good style of hospital style, promote the medical style, tree new wind, the formation of a good medical atmosphere.
5. Strengthen the hospital health environment, to provide patients with a good medical environment.
Our hospital in order to further change the hospital health environment, the departments and people divided. Hygiene area, take the daily cleaning, weekly sweeping, monthly evaluation and notification and other forms of inspection, such as the existence of health corners, the use of spare time to get behind the hospital to clean up the health corners, so that the hospital's environmental outlook has changed a lot.
6. Strengthen the work of the new rural cooperative.
In accordance with the revised operation of the new rural cooperative program, improve the operation and management system of the new rural cooperative, strengthen the supervision of hospitalization and cost control, to ensure the safe operation of funds. Expand the beneficiary surface of the new rural cooperative, enhance the new rural cooperative subsidy standard for major diseases, and effectively reduce the occurrence of poverty due to illness and return to poverty due to illness. Do a good job of publicizing the new rural cooperative policy, do a good job of reporting the cost of publicity, consciously accept the supervision of the masses, so that the masses are satisfied.
Through the implementation of this health care special rectification activities, our hospital according to the problems and rectification measures to seriously improve all aspects of health care, comprehensively promote and enhance the health of medical services, and prevent medical errors and disputes, to provide the masses with a safe and secure medical environment. Strive to pass the acceptance of the Health Bureau to establish a new ethos in the medical industry.