Target 1. Correctly identify the patient's identity
(a) strictly implement the check system to ensure the correct operation and treatment of patients. At least two signs should be used to confirm the identity of patients, such as name, medical record number, date of birth, etc. , but does not include the patient's bed number or ward number.
(two) in the implementation of blood transfusion and other key treatments, the identity of patients should be identified by double check.
(3) There should be identification marks (such as wristbands, fingerprints, etc.) for intraoperative patients, mental illness, consciousness disorder, language disorder and other special patients.
(four) to encourage the application of bar code scanning, face recognition and other identification technologies, but still need to be checked orally.
(5) Strengthen the management of newborn identity.
Objective 2. To ensure the safety of medication and blood use.
(a) standardize the drug management process, and have strict requirements for the storage, labeling and use of high-alert drugs and drugs that are easily confused (sounds and looks).
(2) Strictly implement the management norms for the use of narcotic drugs, psychotropic drugs, toxic drugs for medical use, radioactive drugs and other special drugs, as well as pharmaceutical precursor chemicals and anti-tumor drugs.
(three) standardize the system and process of issuing, reviewing, checking, executing and commenting on clinical medication orders. Formulate and implement the drug reorganization system and process.
(four) to establish and implement the diagnosis and treatment system and technical specifications for the management of antibacterial drugs.
(five) to formulate and strictly implement the rules, regulations and processes of the operation specification, audit, inspection and safe distribution of intravenous drug allocation center.
(6) Establish and strictly implement the system and process of blood storage, blood matching, blood matching and blood transfusion, carry out pre-transfusion indication evaluation and post-transfusion effect evaluation, and implement the whole process management of blood transfusion information system.
Goal 3. Strengthen perioperative safety management?
(a) to formulate and implement the necessary preoperative examination and evaluation of elective surgery (including daytime surgery), strengthen the cooperation of related disciplines during perioperative period, and strengthen the standardized implementation of preoperative, preoperative evaluation and postoperative visit system.
(2) Formulate and implement a unified procedure for identifying the surgical site and invasive operation, and the surgeon who performs the operation will mark the surgical site. The marking should be carried out in the patient's conscious state and incorporated into the preoperative examination procedure.
(3) Establish the system and process of surgical safety verification and surgical risk assessment, implement the WHO surgical safety checklist, and provide necessary guarantee and effective supervision measures.
(four) the selection and use of preventive antibacterial drugs should comply with the relevant norms.
(5) Strengthen perioperative pain management.
(six) to strengthen the management of safe delivery of pregnant women, the implementation of the World Health Organization safe delivery checklist practice guide.
(seven) to establish a complete system of specimen collection, identification, transportation, handover and return, and realize the traceability management of the whole process of specimens.
Goal 4: Prevent and reduce health-related infections.
(1) Establish and improve the organizational system and system of hospital infection management, implement the monitoring indicators of hospital infection and make continuous improvement.
(two) improve the compliance of medical staff hand hygiene, and provide necessary facilities and effective supervision for the implementation of hand hygiene.
(three) the use of qualified sterile medical supplies, follow the requirements of aseptic operation. Ensure safe injection. Safe disposal of medical waste.
(four) the establishment of antimicrobial drug management and monitoring mechanism, the development of multi-drug resistance management system.
(five) the implementation of ventilator-associated pneumonia, vascular catheter-related infection, catheter-related urinary tract infection and other equipment-related infection prevention and control measures, strengthen the corresponding infection monitoring and feedback.
(six) to carry out targeted monitoring of surgical site infection and implement corresponding preventive measures.
Goal 5. Strengthen effective communication among medical staff.
(1) Establish an effective communication mechanism among medical staff, standardize the information transmission process, and ensure that relevant medical care measures are put in place.
(2) Strengthen cross-disciplinary cooperation, advocate multi-disciplinary diagnosis and treatment mode, provide various communication methods and channels for medical staff, and enhance teamwork ability.
(three) establish and improve the clinical "critical value" reporting system, standardize and implement the operation process.
(4) Establish the system and process of voluntary reporting and mandatory reporting of adverse events, advocate learning from mistakes, and build a fair patient safety culture.
(5) Rational allocation of human resources and attention to the impact of medical staff's labor intensity on patient safety.
(6) Prevent hospital violence and ensure that "security personnel" carry out "safe medical treatment" in a "safe environment".
Goal six, prevent and reduce accidental injuries.
(a) to strengthen the management of high-risk accidental injury groups, formulate relevant risk prevention emergency plans.
(two) to carry out risk assessment of accidents such as falling, falling out of bed, stress injury and loss.
(three) to identify the risk of self-attack, evaluate the behavior of self-harm, refusal to eat, suicidal tendency, etc., and formulate corresponding preventive measures and emergency plans.
(4) Improve the reporting and disposal process of accidental injuries, effectively reduce the degree of injuries, and improve relevant risk prevention capabilities.
(five) to strengthen the education of patients and their families to prevent accidental injuries.
Goal seven, improve pipeline safety.
(1) Establish pipeline safety management system and risk assessment process.
(2) Establish the monitoring process of pipeline events, handle pipeline events in time, and reduce the harm to patients.
(3) Establish the reporting process of pipeline events, encourage active reporting, analyze and improve the causes of pipeline events in time, and effectively reduce the occurrence of pipeline events.
(four) the implementation of unplanned extubation risk prevention measures, establish corresponding prevention and disposal plans, and conduct effective drills.
(five) to strengthen the pipeline safety training of medical personnel, encourage and educate patients and their families to take the initiative to participate in pipeline safety management.
Goal 8: Encourage patients and their families to participate in patient safety.
(1) Improve the medical staff's awareness of the importance of patients' participation in the medical process, and communicate information with patients and their families in a timely and effective manner.
(two) to provide patients with a variety of ways and means to participate in the medical care process, to help them correctly understand and choose the diagnosis and treatment plan.
(three) to encourage patients and their families to actively participate in patient identification, surgical site confirmation, infusion, medication, patient transport and other diagnosis and treatment processes.
(four) to guide patients to provide real illness and related information, pay attention to protect the privacy of patients.
(five) to provide patients with various forms of patient safety education and training, to help and guide patients to establish better health awareness and improve health literacy.
Goal 9. Strengthen medical equipment safety and alarm management.
(a) the establishment of medical equipment safety use and management system. Ensure the timeliness, availability and safety of first aid and life support equipment.
(two) to establish a training plan for the safe use of medical equipment, and strengthen the training and assessment of relevant medical personnel.
(3) Strengthen alarm management of medical equipment, enhance alarm management awareness, formulate alarm setting system and norms, alarm response and disposal process, and evaluate the sensitivity of medical personnel to alarm and the impact of alarm on clinical workflow.
(4) Encourage the monitoring and reporting of adverse events related to medical devices, and encourage the evaluation of the safety and effectiveness of medical devices.
Objective 10: to strengthen the safety management of electronic medical record system.
(A) to strengthen the safety level management of hospital electronic medical record system.
(two) to strengthen the training of electronic medical record system, effectively avoid the use of electronic medical record system errors.
(three) to strengthen the electronic medical record system login and user rights management, strengthen patient privacy protection.
(four) to ensure that the input content is standardized, complete and accurate, and to avoid mistakes caused by copying and pasting.
(five) the establishment of electronic medical records closed-loop management of medication orders, the establishment of electronic medical records medication orders knowledge base. Effective application of electronic medical record information in standardized audit of rational drug use in medical orders.
Extended data:
Patient safety objectives cover the following aspects:
1 to improve the accuracy of patients' confirmation.
2. Improve the communication ability between caregivers.
3, retelling, oral or telephone orders drug diagnosis and treatment and critical value test results report.
4. Don't use abbreviations.
5. Measure and evaluate the test results of the critical value of the report.
6. Improve the safety of drug treatment.
7. Remove electrolyte from the patient's area.
8. The classification of labels and containers, the difference between disinfection and non-disinfection.
9, reduce the risk of infection related infectious health care.
10, follow the hand care guide.
1 1, continuous medical treatment, correct and perfect drug treatment.
12, accurate medication time, accurate medication time.
13, reducing the injury caused by patients falling.
14, implement the management plan (process, avoid wrong location, wrong procedure and wrong operation).
15, confirm the procedure before operation, mark the operation position and pause before operation.
16, safety hazard identification.