Hospital department self-examination report (generic 5)
Time is running out, a period of time has come to an end, reviewing the work of this period of time there are many problems, the achievements and shortcomings will be brought together into a self-examination report it. In order to make you no longer for the headache of writing a self-inspection report, the following is my compilation of hospital department self-inspection report (General 5), I hope to be able to help you.
Hospital department self-examination report 1
In the hospital's leadership attention, for the current bad medical behavior of certain medical units, the hospital carried out a comprehensive self-examination and self-correction work inspection. Laboratory Department of the management of the section, quality, safety, service and other aspects of a comprehensive self-examination and self-correction checks. After three days of self-examination and self-correction, against the relevant medical rules and regulations, found a number of hidden dangers, the development of relevant measures. Briefly summarized as follows:
1, the quality of specimens most of the specimens qualified, unqualified specimens have a record of rejection and re-sampling treatment. Problems: insufficient communication with the Department of Nursing and nursing care in the districts, to more comprehensive and timely reflection of the quality problems in blood sampling. Measures: Quarterly will be related to the quality of specimens in the form of a table to reflect to the nursing department, in order to promote the improvement of the quality of pre-test.
2, indoor quality control all carry out the project can adhere to the daily indoor quality control, there are records, the point of loss of control has been analyzed, there is treatment. Quality control is good.
3, inter-room quality control can participate in the annual Foshan City, Guangdong Province, the Ministry of Health of various types of projects inter-room quality. There are records and feedback analysis, strict control of the person in charge of quality. The same type of analytical instruments have measured the value of regular comparison, the data show that the results between different analytical instruments in a reasonable acceptable range.
4, the critical value reporting system of each laboratory can be seriously implemented, there are records and processing. Problems, found 1 case of false critical value improper handling. Measures: Strengthen the staff's business ability to learn and training, and constantly improve their own professional ability. The handling and reporting of critical values are standardized and implemented. The company's website has been updated with the latest information on the latest news.
5, on dangerous goods, safe use of electricity, fire hazards inventory. Hazardous materials are managed under lock and key, and there is a registration of use. Not found electricity, electrical use of safety hazards. No potential fire hazards were found. Firefighting equipment qualified and stored in accordance with the requirements.
6, the service ability to send reports on time, the inspection report timely rate of 95%. Service satisfaction of 90%. Rating for the time 84 points. Service level and quality still need to be continuously improved. Strengthen the ideology and professional ethics education, establish a new style of the industry, create a civilized service window.
The self-examination and self-correction inspection, to improve the quality of our test has a great role in promoting, to protect medical safety, eliminate medical hazards has a positive significance.
Hospital department self-correction report 2
xxx hospital seriously implement the spirit of the District Health Bureau safety work conference, the safety of production, fire safety work into the daily work of the agenda, the development and implementation of the management system, publicity and education system. Adhere to the prevention-oriented, prevention and treatment, responsibility for people, in place. Specific self-examination results are reported as follows:
First, the work of production safety responsibility
1, 20xx year no major medical safety responsibility accidents.
2, basically improve the medical management system, the strict implementation of the operating procedures, no medical errors, medical accidents; no occupational exposure events.
3, medical errors focus on prevention, the hospital set up a quality and safety control management committee, set up a quality control group in the department, clear medical safety first person responsible for the formation of "one post, two responsibilities" mechanism, everyone signed a safety responsibility, and regularly convene meetings on quality and safety control of medical care to ensure that medical errors, accidents do not occur.
4, regularly carry out quality control self-examination work, and the hidden dangers of medical accidents on a deadline for rectification; regular training in medical technology knowledge, improve the business capacity of all medical personnel, and effectively prevent the occurrence of medical errors and accidents.
5, the strict implementation of the access system for medical personnel, obtaining health technology qualification certificate of personnel can be on duty to practice.
Second, the responsibility for fire safety work
1, the establishment of a sound organization, clear work responsibilities
Fire safety is an important part of the work of the hospital, is the relationship between the staff and the patient's life and safety, the safety of the hospital's property of the top priority. In this regard, our hospital was established in 20xx to the administrative director as the head of the group, the safety officer as the first responsible person, the director of each department for the direct responsibility of the fire safety working group, fully responsible for the daily work of fire safety.
2, strengthen the publicity and education, enhance fire safety awareness
I attach great importance to fire safety work, and constantly strengthen the fire safety knowledge of all staff training, through centralized and decentralized learning combined way, actively learning fire safety knowledge, effectively improve the fire safety awareness of the whole staff, set up a "everyone is a fireman, fire work is everyone's responsibility. Firefighters, fire prevention is everyone's responsibility" concept, to ensure that each employee is skilled in the use of fire fighting equipment, with the initial fire fighting and escape self-rescue common sense, and effectively implement fire safety work into the daily management.
3, seriously carry out fire safety self-check, investigate and eliminate fire hazards
The hospital system provides for weekly fire hydrants, fire extinguishers, safety channel signs, power lines, liquefied petroleum gas canisters, drinking fountains, computers, printers, sockets and hubs and other electric and gas facilities in the hospital hallways by the Logistics Section to conduct a comprehensive self-check over the past year, did not find that the power lines are aging, exposed, Burning, the presence of flammable and explosive substances, power-consuming equipment overloading and other phenomena.
In short, for the hospital, medical safety and fire safety work is the most important, we will implement the "safety first, prevention first, comprehensive management" policy, strengthen supervision and inspection and strengthen the daily management work, improve the awareness of the whole staff safety responsibility, and effectively do to prevent problems before they occur, for the hospital staff and children and parents to create a safe and harmonious working environment. To create a safe and harmonious working and medical environment for hospital staff and children and parents.
Hospital department self-examination report 3The county gradually implemented the standardized management of township health hospitals. Through the convening of a mobilization meeting, issued an implementation plan, clear work objectives and tasks, the development of work measures and other work methods, the first part of the township health center pilot as a guide, and gradually pushed out in the county. So far, this work has been fully implemented in the county 13 township health centers. According to the requirements of the higher level, now the county township health hospitals standardized management of the progress of the pilot work of self-reporting is as follows:
First, the work of the achievements
1, through the medical aspects of health hospitals, clinical departments and public **** health aspects of the standardization of the construction of the vaccination clinic as well as the environmental construction, and further improve, including the configuration of the departments
2, through the township health center people, talent, material unified management, so that the health center of the unit and the subordinate jurisdiction of the village health room of the technical personnel deployment, qualification access, funding, asset management, as well as business guidance and work co-ordination, public **** health, health care market supervision, etc., to rationalize the management system of the township health centers.
3, completed the township health center personnel distribution system reform, in the implementation of the director of the tenure of the target responsibility system and improve the basis of the management system, the township health center section set up into the public **** health and medical two parts, clear township health centers to the public **** health service is the main focus of the center health center to be on the premise of this, and to further improve the level of medical technology, guidance around the general The function of the operational work of the health center. The establishment of a strict performance appraisal system, the allocation of personnel wages and the services they provide and labor contributions linked to improve the internal vitality of the township health centers, stimulate the work of the majority of cadres and workers enthusiasm.
4, in the health hospital administration and business aspects of both the implementation of institutionalized management. Set the hospital leaders and department heads of the rank and file target tasks. The implementation of responsibility, rights and benefits of the combination of job responsibility system, the establishment of a sound system of medical care work, including the clinical departments, shift handover, standardized writing of medical documents, error and accident registration, disinfection and isolation, to prevent medical disputes, to eliminate the occurrence of medically liable accidents.
5, and actively carry out rural health institutions to support the work of counterparts, arranged for five county-level health care institutions to support 13 township health centers, arranged for 13 township health centers according to its regional division, responsible for the county's 248 village health clinics of the packet system of responsibility, the practical establishment of a sound rural three-tier health care network of infrastructure, maximize the role of its due. Through the signing of the form of counterpart support agreement clearly defines the work objectives, work tasks, mode of work, time and both sides of the responsibility and power to improve the management of primary health care institutions at all levels and service capacity, so as to make the recipient of the township health centers and village health rooms in the environment, connotation of the construction of the construction of a significant change in the rectification.
6, strengthened the township health center accounting, health prevention specialists, maternal and child specialists, co-medicine specialists and other specialists management, the development of the specialists in the employment and assessment of the management approach, all the specialists employment must be declared by the health center, the Health Bureau for approval of the employment, without the permission of the competent authorities at the higher level, the health center is not allowed to arbitrarily change to ensure that the health center specialists team of stability, and effectively promote the financial and public **** health and other work is carried out smoothly.
7, the development and issuance of the "Huaxian township health center director norms of ten," to strengthen the management of the health center director. Clearly require the director of the health center in accordance with the relevant laws and regulations of the country to carry out all the work, subject to the management of the Health Bureau, to ensure smooth flow of orders, in accordance with the "Huaxian township health center director norms of the ten" requirements of self-discipline, to complete the work of the task on schedule.
Second, there are problems
1, due to historical reasons, the individual township health centers shortage of technical personnel, small scale, the existing medical equipment can not play its due role. Solution: is through the temporary secondment, commissioned training and other ways to be resolved health centers.
2, uneven distribution of medical equipment resources. Solution: The Health Bureau through the survey mapping statistics, the county township health centers all damaged, idle medical equipment for unified registration, repair, maintenance, debugging, redeployment of the use. In order to improve the utilization of equipment, convenient for the masses to seek medical treatment.
3, the village health room standardized construction, township health center standardized management and rural health services integrated management of the three inherent *** the same point of effective combination, Qiqi grasp *** management, scientific and rational arrangements for the deployment of a substantial increase in work efficiency.
In order to steadily implement the national basic drug system, and effectively solve the masses of "difficult to see a doctor, see a doctor expensive", the implementation of the party and the country's policy of benefiting the people, we strengthened measures, pay close attention to the implementation of the solid promotion of the "drug three unified work".
Now I will be the jurisdiction of the drug "three unified" work self-inspection report as follows:
First, I set up a "three unified" work leadership group, headed by the president. Developed a pharmacy quality management policy, objectives, the preparation of quality management program documents and operating procedures, the implementation of regular inspections combined with routine inspections, so that the quality of our hospital pharmacy management to achieve evidence-based, rules and regulations to follow.
Second, our hospital from October 20xx to now has been by the "three unified" enterprise distribution, the use of basic drugs 100%.
Third, the standardization of my jurisdiction, 15 village clinics, have all signed a contract with the "three unified", the drugs purchased by the "three unified".
Fourth, we have all the staff of our hospital for the "Clinical Guidelines for Essential Medicines" training, clinicians can now do reasonable and safe use of essential medicines.
"Three unified" distribution process of the main problems:
1, the distribution of enterprise drug varieties are not very comprehensive, the individual must be drugs can not meet the hospital and village health center clinical medicine. The first time I saw this, I had to go to the hospital to see the doctor.
2, the drug distribution process delivery is not timely.
3, part of the drug price is expensive.
In the future work we are determined to implement the reform of the national essential drugs system, increase the publicity and supervision of the work, improve the drug "three unified" long-term regulatory mechanism to ensure that the drug "three unified" work smoothly.
Hospital department self-examination report 4In order to implement the implementation of the Ministry of Health "hospital management year activities program", the implementation of the unified arrangement of the hospital department, the medical technology section through the study, combined with the base situation of the department, in accordance with the implementation of the "hospital management year activities program" activities required to strengthen the internal construction of medical institutions.
The development of the hospital does have the problem of medical safety hazards. The main reason behind these problems is that the department of the various systems are not fully implemented, security awareness is weak, management and supervision of the work of lax, ignoring the connotation of the construction, in the context of the current reform of the medical and health system, to effectively strengthen the industry management, stabilize the medical order, to ensure that medical safety is particularly important. Under the theme of "patient-centeredness and improvement of medical quality", we have carried out the search and organization of medical diagnostic techniques and taken targeted measures to eliminate various hidden dangers that are unfavorable to patients. Establishment of long-term management mechanism. Thoroughly implement the core system and standardize the operation procedures of various examinations. The report was written carefully and carefully to provide the clinic with effective diagnostic opinions of the patients' examination.
The establishment of an orderly workflow, ultrasound, color ultrasound in the case of many patients, the inspection process is chaotic, some patients wait too long, family members have opinions, quarrels, in this regard, must be set up to check the registration window, according to the order of the number of the inspection, [except for emergencies]. To prevent the first to induce conflict. ultrasound examination of the number of patients increased significantly, the current two units do not meet the needs of the development of the situation, must increase the number of units, supporting the computer print report, standardize the report form of the checklist, the results of the examination report should be examined by the physician's signature review is issued. ultrasound medical and technical staff shortages should be resolved urgently. To solve the duty regulations, post implementation to the person, the implementation of 24 hours on duty system.
Endoscopy room, most people are late for work, anesthesiologists are not in place on time, and patients often wait too long. Check according to the principle of first-come-first-served, gastroscopy nurses gastroscopy equipment to be strictly disinfected, the preparation of disinfectant pay attention to the concentration, effective time, to prevent the occurrence of hospital-acquired infections, the quality of medical diagnosis, to do the inspection to be careful, the work should be recognized, the attitude should be heart, all in accordance with the operating specifications, to prevent the occurrence of errors. Enteroscopy in the morning and afternoon, do a good job of cleaning and cleansing before the examination. All everything should be for the sake of the patient, to solve the problem of difficult and expensive to see the patient, to do sincerely for the patient service noble ideas.
The new equipment 16-row spiral CT has been carried out more than half a year, since the development of the basic perfect with the clinical examination of the 'needs, but still do not play the 16-row spiral CT full function of the examination, and gradually the scope of the examination of the development of the broad and deep aspects of the development and development of new projects. Although the current achievement of a large number of performance, but there are still many problems.
System implementation is not in place, the operating procedures are not standardized, especially in the abdominal examination, not in accordance with the normative requirements for patients to do a good job before the examination, affecting the quality of the image, resulting in ambiguous diagnostic quality.
Diagnostic quality control is not strict, the phenomenon of misdiagnosis and misdiagnosis exists, in terms of the need to step up efforts to put a good quality, the implementation of the three-tier review and audit system, in the quality of control to put more effort.
Provide for the time to take the film and report the results of the time, emergency within half an hour to take the film, an hour to take the results, non-emergency examination, head examination in the morning, 4:00 pm to take the results of the chest, abdominal examination at 10:00 pm to take the results of the next day, abdominal examination of the patient should be swept plus enhancement, a one-time payment, to reduce the patient back and forth to the trouble of the payment.
Accelerate the new project to carry out business knowledge learning to vascular imaging parts of the examination as the future work of the main topics, image 3D reconstruction processing, more importantly, to speed up the development of CT diagnostic technology, through short-term training, to participate in online exchanges to learn and discuss, and gradually improve the level of professional and technical diagnostic.
Troubled case discussion is not standardized. There is no perfect system established, the physician expresses his opinion without record and considerable information archives, case tracking feedback, lack of serious summary. In this regard, we must begin to improve the establishment of a long-term mechanism, the development of effective measures and programs, focusing on film reading, case discussion and analysis, report review and verification, case tracking records archives, and constantly summarize, and strive to learn new technologies, open new projects, give full play to the function of the 16-row helical CT, put a good quality, speed up the angiographic, faux-endoscopy, three-dimensional reconstruction of the technical knowledge to learn, to improve the diagnostic expertise of CT imaging. The technical level of CT imaging specialty diagnosis.
Labor discipline is too poor, late for work, the implementation of the rules and regulations of the hospital is not in place, on duty is not on duty, sometimes leading to the patient's family have opinions. At present, ultrasound, color ultrasound, CT has been implemented 24 hours on duty system. The solution to the emergency patients with the arrival of the investigation.
Through the study and implementation of the hospital management year activities program, to further recognize that all medical personnel should be all for the sake of the patient concept, to solve the problem of difficult and expensive to see a doctor, to do sincerely for the noble idea of patient service. For the majority of patients to provide quality services, to accelerate the development of the hospital master plan a better future, *** with efforts.
Hospital department self-examination report 5In order to conscientiously implement and carry out the strict management of medical and health institutions in accordance with the law of the spirit of the instructions, to improve the standardization of hospital work institutionalization level, to strengthen the connotation of the hospital quality construction and to ensure medical safety, the department of all the work of self-examination and rectification, the situation is reported as follows:
First, the basic situation of health care quality, safety management
(a) a sound safety management system, clear responsibilities, responsibility.
The medical quality and safety management program and assessment standards have been formulated, and the duties of each medical management system have been improved and regularly supervised. We have set up the diagnosis and treatment process of specialized and professional diseases, especially invasive examination and treatment (such as the process of interventional diagnostic and treatment operation), and carry out clinical work in strict accordance with the process and diagnosis and treatment guideline, so as to ensure the quality of medical care and medical safety.
(2) Strengthened education on medical quality and medical safety, and the safety awareness of medical staff is constantly improving.
Through various forms of learning, the quality and safety education of department members, strengthen the training and assessment of laws and regulations and rules.
(C) improved the prevention of medical malpractice disputes, prevention of accidental injuries caused by non-medical factors, the establishment of medical disputes prevention and treatment mechanism.
(4) in the management of nurses, can be strictly in accordance with the provisions of the Nursing Regulations implementation of nursing management organization of nursing staff to seriously study the Nursing Regulations, to ensure that to know the law, abide by the law, according to law practice.
(5) according to the national "hospital infection management approach", according to the actual situation of the hospital and the task requirements, to strengthen the knowledge of hospital infection training, improve the medical staff of the hospital infection control and disinfection isolation awareness.
Second, effectively strengthen the quality of nursing safety education
(a) establish a patient-centered service concept, and vigorously advocate the change of passive to active thinking.
(2) clear job responsibilities, summarize the experience, establish a long-term mechanism for continuous improvement of nursing quality, improve the level of nursing.
(C) to strengthen the nursing "three basic" learning assessment. Improve the nursing staff's business skills and theoretical knowledge, and strengthen the learning of new business and new technology.
(D) the strict implementation of the implementation of medical advice system, increase the supervision.
(e) Strengthen the training of aseptic operation procedures, and strengthen the management of aseptic articles.
(F) the implementation of the system, strengthen the communication between doctors and patients to enhance their understanding and conscientiously implement the signing of a variety of informed consent.
Three, there are shortcomings
(a) the implementation of the rules and regulations of some not in place.
(b) The writing of medical records and nursing instruments are defective.
(3) medical dispute prevention and handling mechanism needs to be improved.
(D) Nursing management needs to be improved.
Four, specific corrective measures
(a) conscientiously implement the laws and regulations, establish and improve the rules and regulations, will be the core system to strengthen the training, to ensure that the system is in place. Strengthen the quality of medical management, the implementation of medical quality assurance program assessment of the rules and regulations and personnel job responsibility system implementation and implementation, to ensure medical safety and quality of service, and constantly improve the level of service. Implementation of the "Practicing Physicians Law", "Nurses Regulations", "Regulations on the Treatment of Medical Accidents" and other laws and regulations, with medical quality management as the core, focusing on the strict implementation of various medical systems, measures, protocols, the quality of medical records, basic medical quality and medical operation standards. It also carries out the study of laws, regulations and rules, and repeatedly strengthens the legal awareness of medical staff. Using the morning meeting and the usual business study time for legal knowledge and prevention of medical disputes case lectures, and regularly convene a security analysis meeting.
(2) the establishment and improvement of medical waste disposal management, nosocomial infection and disinfection management, waste leakage treatment program and other relevant rules and regulations. Complete records of the sources, types and quantities of medical waste are kept, and regular monitoring of disinfection effects is carried out. Strengthen the supervision of nosocomial infection, conscientiously implement the "Hospital Infection Management Measures", establish a perfect hospital infection management management organization system, strengthen the monitoring of hospital infection cases, disinfection and sterilization monitoring and hospital infection reporting system, and continuously improve the management of hospital infection control.
(2) to strengthen the rational use of clinical medication, strict implementation of the "Drug Administration Law", "prescription management approach", "the guiding principles for the clinical application of antibacterial drugs" and other laws and regulations, to strengthen the management of prescriptions, the implementation of the prescription review system, to ensure the rational use of medication.
(C) Strengthen the supervision of medical cases. The establishment of a sound case quality monitoring, evaluation, feedback system, focusing on strengthening the operation of real-time monitoring and management of cases, to improve the standardization of medical record writing. With reference to the "basic norms of medical record writing", "medical institutions, medical records management regulations" for medical staff to write medical records training, strengthen management, strictly in accordance with the norms of writing medical records.
(D) the establishment of medical disputes prevention mechanism and handling mechanism, improve the reporting system, timely handling and proper resolution of medical disputes, poor rectification of hidden dangers of accidents, the various special remedies dragged, not in accordance with the provisions of the timely reporting to be held accountable. Implement the medical safety responsibility system. According to the principle of "from top to bottom, one level to grasp one level, and from bottom to top one level to protect one level", the safety work is implemented at all levels and specific to the person. To take the initiative to report nursing adverse events, improve the special nursing quality management system, such as various types of catheter dislodgement, patient falls, bedsores and so on. The company's goal is to improve the quality of care for patients who have fallen out of catheters and bedsores, and to improve the quality of care for patients who have fallen out of catheters and bedsores.
(E) strictly in accordance with the provisions of the Nursing Regulations, the implementation of nursing management, the development and safety of nursing work system, post system, nursing routines, operating procedures, and to ensure the implementation. The development and implementation of nurses' job responsibilities and work standards, standardize clinical practice behavior. Establish a performance appraisal system for nurses, combining the appraisal results with the evaluation of nurses' merits and priorities according to the quantity and quality of nurses' clinical nursing work and the satisfaction of hospitalized patients. Establish a perfect nursing management organization system. The implementation of the target management responsibility system, clear responsibilities.
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