I. General Provisions
1. Purpose: In order to effectively improve the quality of medical care and medical safety management, standardize the active reporting system of medical safety (adverse) events, enhance the awareness of all medical personnel of risk prevention, timely detection of medical safety (adverse) events and safety hazards, and to promote the continuous improvement of quality of medical care, the provisions of the special formulation.
2. Scope of application: medical personnel in the diagnostic and treatment activities, due to diagnostic and treatment errors that may affect the results of the patient diagnosis and treatment, increase the patient's pain and economic burden, may lead to medical disputes or medical accidents; due to disputes that may affect the normal medical order or the personal safety of the medical staff; due to the medical environment or medical equipment and other non-diagnostic reasons for the injuries caused by the hospital; hospital infection; patient sudden death, falling, self-inflicted injuries, suicide, disappearance and other events.
II. Reporting Requirements
(I) Classification and Scope
Class I (major) events: death or serious disability of patients due to negligence in diagnosis and treatment; events that may lead to major medical disputes or mass incidents, affecting the medical order and social stability, and causing serious adverse impact on the society; serious omission of diagnosis and treatment; nosocomial infections; errors in the selection of surgical patients, surgical sites, and surgical methods; anesthesia-related events; and events that cause serious harm to patients or medical staffs. and surgical method selection errors; anesthesia-related events.
Level II (ordinary) events: patients with mild disabilities or organ and tissue damage due to diagnostic and treatment defects; the use of the wrong drugs, specimen error or loss, the wrong examination site or wrong report; in the hospital caused by a greater adverse impact of the incident.
Class III (hidden) events: the fact that the error occurred, but the department in a timely manner to resolve, did not cause the patient's organism or functional damage; due to poor communication between doctors and patients or doctors and patients language and behavior conflict, in the hospital caused some adverse effects of the incident.
Ⅳlevel (accidental) events: patient falls, falling out of bed , burns, self-inflicted injuries, suicide, disappearance and other events.
(B) report the principles and scope
1. Reporting principles: the provisions listed in the mandatory reporting category, major medical disputes, adverse events, nursing care, infectious diseases, and hospital-acquired immunodeficiency syndrome reporting system has special requirements, according to the implementation of special provisions.
2. The scope of the report: involving medical, nursing, hospital infection, equipment failure and other non-medical factors in accordance with the provisions of the event reported to the relevant functional departments; caused the death of the patient or the serious consequences of all the adverse events need to be reported to the Medical Department.
Reporting departments of various events:
(1) Medical disputes, hidden problems and adverse events are reported to the Medical Department. (2) Nursing disputes, hidden dangers, adverse events reported to the Nursing Department. (3) Hospital infections, adverse events, infectious diseases reported to the Infection Management Department. (4) Adverse drug events reported to the Pharmacy Department.
(5) Environmental facilities, accidental injuries reported to the Department of Aftercare. (6) Equipment, equipment adverse events reported to the Equipment Division. (7) billing and cost-related adverse events reported to the Finance Division (8) medical ethics and medical ethics adverse events reported to the Supervision Office (3) Reporting forms: telephone, Internet and written reports. (D) Reporting requirements
1. medical staff in the occurrence or discovery of medical safety (adverse) events, in addition to immediately take effective measures to prevent the expansion of the consequences of damage, should immediately report to the director of the department (head nurse) or the temporary head of the department (head nurse) or the temporary head of the department should immediately go to the scene of the treatment, and the event of a preliminary assessment, according to the category of the adverse event to the relevant departments immediately report by phone, during the daytime, the director (head nurse) or the temporary head of the department should immediately go to the scene to deal with, and preliminary evaluation, according to the adverse event category to the The relevant departments report by phone, fill out the medical safety (adverse) event report form for written reports within two hours during the day, and complete the written report within 24 hours after work or on holidays.
2. The department concerned needs to fill in the medical safety (adverse) event report form carefully, and organize the discussion within the department into a booklet for proper preservation and archiving.
3.