Medical risk prevention self-examination report

Introduction: effectively establish the "patient-centered" concept of medical services, combined with the development of a new round of "three good and one satisfaction". The following is my carefully organized medical risk prevention self-examination report, welcome to read!

Medical risk prevention self-examination report (a)

According to the requirements of the rectification of medical quality and safety rectification work, my department carried out a comprehensive inspection of medical quality. Now on the results of self-examination and the next step of rectification measures reported as follows:

First, there are problems:

(a) certain medical core management system and the implementation of insufficient places.

Individual medical personnel quality and safety awareness is not high enough, the first physician responsibility system, case discussion system, shift handover, consultation and other core systems sometimes can not be well implemented, case discussion and coping with the situation. Patient condition assessment system is not sound, the risk assessment of surgical patients, limited to preoperative discussion or preoperative summary, has not yet established a written risk assessment system.

(b) The application of antibacterial drugs still exists in the irrational imagination.

Individual medical staff antimicrobial drug use is unreasonable, the common cold also use antibiotics; perioperative prophylaxis is unreasonable, antibiotic application grade is too high, too long.

1, the course of the record of the revised medical advice, positive test results lack of analysis, the analysis of the content of the room less, some like a running account, too formalized.

2, the existence of informed consent to inform, sign irregular, drugs and disposable high and low value consumables and other self-financed items not signed informed consent.

3, medical records are printed, copy and paste without timely checking, name, hospitalization number does not match the situation still exists, handwriting scribbles, there is the phenomenon of alteration.

(d) individual medical staff's sense of service is not strong, the work sometimes have ? The first time I saw this, it was a very good thing that I was so happy to see you. phenomenon, poor awareness of medical risks, weak legal awareness, doctor-patient communication skills are not enough, the medical risk of underestimation, resulting in insufficient communication between doctors and patients in place.

(E) the level of professional and technical level needs to be further improved, can not well meet the needs of patients, first aid skills need to be further rehearsals.

(F) department management is not enough, the problem found after the regular supervision of rectification and implementation, resulting in long-term problems.

Second, the next corrective measures:

(a) further strengthen the quality and safety education, improve the medical staff's safety, quality awareness.

The medical staff generally exists to pay attention to professional knowledge and despise the learning of quality management knowledge, the lack of quality management knowledge, 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. Therefore, training all medical staff in quality management knowledge and enhancing quality awareness is one of the basic tasks to improve medical quality. The first step is 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) further increase the management of the department and supervision and inspection efforts to ensure the implementation of the core system.

1, to further strengthen the quality of medical care three physician room and medical record writing inspection work, focus on the practical effect, can not be a formality, on the problems found in addition to face-to-face explanations, a week a circular, on repeated offenses must be punished through financial penalties, to give disciplinary action.

2, to strengthen the three basic training and assessment, while the professional knowledge in accordance with the beginning of the year learning program to gradually learn in place, in the section of the wide range of job training activities, we must continue to improve the assessment methods, serious assessment of the discipline, focusing on the effectiveness of training.

3, strengthen the management of case quality.

Carry out training on the standardization of medical record writing, and further improve the relevant systems and medical record inspection standards to ensure that the standardized writing of medical records, and timely filing and management of hospitalized medical records.

4, according to the Ministry of Health "to further strengthen the management of the clinical application of antimicrobial drugs," the spirit of the notice, the development of the Department of the specific implementation of the approach and the system of rewards and penalties, focusing on the monitoring of perioperative prophylaxis to prevent the use of medication, to prohibit the abuse of antibiotics.

(C) further strengthen the professional ethics education in the department, and effectively improve the service level of medical personnel.

According to the Ministry of Health, "medical personnel medical ethics norms and implementation measures" and the requirements of the group education activities, medical ethics education for medical personnel. Cultivate modesty and prudence, not proud of the work style, rooted in the masses, service in the front line, determined to do a noble medical ethics, respected by the people of the medical workers, and really set up a? People-oriented, patient-centered? The concept of the patient as their loved ones, to really do, not to seek personal gain.

(D) continue to strengthen the doctor-patient communication skills training for the patient's admission, medical intervention, patient call, surgery, special tests, changes in the condition of the doctor-patient communication skills training to enhance the understanding of the doctor-patient to reduce the incidence of medical disputes, and to ensure the implementation of the signing of the informed consent form.

Medical risk prevention self-examination report (two)

According to the requirements of the medical quality and safety rectification activities of medical institutions, our hospital has carried out a comprehensive inspection of key departments and key sectors. Now on the results of self-examination and corrective comments, measures and specific corrective responsibility to implement the report is as follows:

First, the basic situation of our hospital medical quality and safety management review:

(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 responsibilities. 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 continuous improvement.

(2) Strengthened medical quality and medical safety education, medical staff safety awareness is constantly improving.

We conducted quality and safety education for the whole staff through the form of safety conference, and signed safety responsibility letters with the relevant personnel of each department. We have strengthened the training and assessment of laws, regulations and rules. Organized ? Medical quality and safety? and other trainings. After the end of the safety inspection check, the hospital quality control section held a meeting to seriously study and analyze the problems and disputes found in the inspection of hidden dangers, to find out the core problems and corrective measures, and then held a meeting of the section chiefs, head nurses, business backbone for quality evaluation, 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.

(d) Nursing management

(1) Nursing management organization

able to strictly in accordance with the provisions of the Nurses Regulations implementation of nursing management, the organization of the head of nurses and nursing staff to seriously study the "Nurses Regulations", to ensure that the knowledge of the law, abide by the law, and practicing in accordance with the law.

(2) Nursing human resource management

The annual development of nurses on-the-job training program, including the 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

According to the national "Hospital Infection Management Measures", our hospital has established and improved the hospital infection control team. The dean of business serves as the director of the hospital infection management office,

(2) The work responsibilities of the hospital infection control management organization have been implemented

Our hospital, according to the actual situation and task requirements, annually formulate a plan for the management of hospital infection work to achieve the implementation of the organization and responsibility to a person. Hospital infection management meeting is held every year to summarize the recent hospital infection management work, solve the daily work found with general problems, and arrange 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 disinfection and isolation of health care workers

(4) seriously carried out hospital infection control and disinfection and isolation of the monitoring work to reduce the rate of hospital infections, there has never been an outbreak of epidemic phenomenon of hospital infections. Strengthened the management of single-use supplies. Each department strictly enforces the ? Disposable sterile medical supplies management measures? The single-use medical and hygienic supplies are purchased, stored and issued by the Equipment Section. The three certificates are complete. Three certificates are complete. Each department receives the supplies according to the need, so as to achieve the first lead and use within the validity period. After the use of single-use supplies, by the person centralized recycling, prohibit repeated use and return to the market.

Second, there are problems:

(a) Some medical management system is still not enough place to implement.

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. The patient's condition assessment system is not sound, the risk assessment of surgical patients, limited to preoperative discussion or preoperative summary, has not yet established a written risk assessment system.

(b) The application of antibacterial drugs still exists in the 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.

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 form missing signature, self-pay medication did not sign informed consent.

Three corrective measures:

(a) 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 it can not consciously and actively apply the quality requirements and daily medical work, it is difficult to ensure that the quality objectives of the ` realization. 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 responsibilities of personnel at all levels. Our hospital has spent great efforts on system construction, compiling various laws, 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 2013 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 management of medical staff to learn the basics of quality 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 the 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, 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 the quality of the case. To further improve the relevant systems and medical records inspection standards, in order to develop incentives and penalties to ensure the timely filing of hospitalized medical records and 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.

(C) to further strengthen the professional ethics education, and effectively improve the level of service of medical staff.

1, according to the Ministry of Health, "medical personnel code of medical ethics and the implementation of the requirements of the" medical ethics education for medical personnel. Let the medical staff clear:? The first medical family in the character? Medical ethics is a code of conduct and self-discipline of medical personnel. To establish the concept of wholeheartedly serving the people, cultivate modesty and prudence, not proud of the work style, and aspire to be a noble medical ethics, respected medical personnel. Every physician should memorize the content of the Convention on Strict Self-Discipline and Honest Service for Physicians, and should truly establish the ? People-oriented? The patient-centered approach is the key to the success of the medical profession. Patient-centered? The concept of the patient as their loved ones, not for personal gain.

2, the hospital office has developed incentives and penalties to ensure that medical staff in the hospital practice to have a good service attitude. Attitude determines everything, only correct attitude, in order to recognize the starting point. To always keep in mind that we are in order to save lives, the patient's interests above all. Never allow any excuse in the diagnosis and treatment work to the patient to take indifference, shirking, rude and other irresponsible attitude. No matter what time, what occasion, no matter what the situation, what happened, do not bring bad emotions to deal with patients. To be good at self-regulation, always keep a good state of mind on duty, the sunny side of their own fully displayed to the patients.

(D) to meet the psychological needs of patients, close the doctor-patient relationship, reduce disputes, and create a harmonious environment.

Patients in the hospital is very complex psychological, they need to be cared for, respected, accepted, need to understand his diagnosis, treatment information, need to feel safe and eager to get well soon, at the same time, they will also have the future of the family, work and other social issues of all kinds of worries. All of these need to be well understood by healthcare professionals and resolved or satisfied. First of all, health care personnel must be dressed neatly, kindly, energetic, take the initiative to introduce themselves to the patient is their sub-doctor or nurse, so that the patient gets a good impression of the health care personnel to produce a sense of trust and a sense of reliance, so that the patient's emotional stability, the family is satisfied with peace of mind in the diagnosis and treatment of the process in order to take the initiative to cooperate with, and to establish a proactive and cooperative relationship between the doctor and the patient. Patients and their families in the treatment process, may urgently request health care personnel to convey diagnosis and treatment information for them in a timely manner, which is also the right of patients and their families. Therefore, healthcare professionals must communicate with them in a timely manner and seek their opinions so that patients and their families can actively cooperate to achieve the desired purpose. If you can not communicate with patients and their families frequently about their conditions and treatment plans, and their need to know can not be satisfied, it will also cause misunderstandings and even cause medical disputes.

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