1. Medical quality inspection self-examination report
A medical quality management
I hospital pay close attention to the quality of service, strict prevention of medical errors, according to the law, civilized medical practice. The hospital has set up a medical quality management leading group headed by XXX vice president, regular sampling of prescriptions, medical records, timely feedback to the relevant responsible person, supervision of the quality of medical care throughout the hospital. All kinds of single disease quality control to meet the city and district standards.
Second, the medical instruments
Strictly abide by the "basic specification for the writing of medical records" in the requirements for patients to do objectively, truthfully, accurately, timely and complete writing of all medical instruments.
Third, the rules and regulations
Our hospital to improve and implement a series of rules and regulations, improve the management system, including the thirteen core systems, new technology access system, pharmaceutical management system, emergency public **** event management system. For patients who visit the hospital, they are required to present their medical card and ID card when registering, and hospitalized patients are required to submit a copy of both cards during hospitalization, which is carefully checked to prevent impersonation. The company's website is a great source of information about the company's products and services, and the company's website is a great source of information about the company's products and services, and the company's website is a great source of information about the company's products and services.
I strictly abide by the health insurance system, the organization of the hospital medical staff to repeatedly and seriously study the relevant policies of the health insurance, and the assessment work, the assessment results and personal interests linked to the distribution.
Fourth, the basic drug system
For the examination and treatment of patients in the clinic or hospitalized patients, the hospital is strictly in accordance with the provisions of the "Basic Drug List". Each physician is required to strictly abide by the code of ethics of practice, and effectively achieve reasonable inspection, reasonable use of medication, reasonable treatment, reasonable fees, and can use low-priced drugs do not use high-priced drugs, and effectively reduce the burden of medical costs on farmers. The stock of medicines in the pharmacy reaches more than 90% of that stipulated in the catalog. The amount of medication prescribed is strictly controlled, with no more than 3 days' worth of medication for hospitalized patients and no more than 7 days' worth of medication for discharged patients; large prescriptions, favored prescriptions, and abuse of medication are strictly prohibited, and the number of days of discharged medication shall not exceed the actual number of days of hospitalization. Strictly in accordance with the provisions of the inspection, and resolutely put an end to the phenomenon of one person's health insurance, the whole family medication.
V. Medical cost control
Our hospital in strict accordance with the provincial, municipal and district price, health, finance and other departments jointly formulated the fee standard. Pay close attention to the connotation of construction, improve service quality, shorten the average length of stay of patients, and strictly control hospitalization costs.
Sixth, medical support
This year, the city and district health bureau has increased medical support, the city infectious disease hospitals, district hospitals have experts, professors to the countryside for medical support work to improve the professional knowledge of the front-line medical staff, improve the knowledge structure, update the latest professional dynamics, are of great help.
Seven, the current shortcomings
1, due to insufficient funds, some medical equipment can not be timely maintenance or update, to a certain extent, affecting the relevant business in-depth, professional development of the lack of energy.
2, senior Chinese medicine practitioners have a poor grasp of computers, failed to realize all the electronic prescriptions, for the improvement of outpatient co-ordination there is a certain degree of resistance.
3, found that individual physicians have outpatient prescription failure phenomenon, including prescription format is not qualified, outpatient antimicrobial drug use ratio is greater than 20%.
Eight, the future direction of efforts
I must take this hospital level review and annual assessment as an opportunity, under the leadership of the higher business administration, strict compliance with the "Regulations on the Management of Medical Institutions", strengthen management measures, optimize the quality of personnel, pragmatic, pioneering and innovative, and constantly improve the quality of health care services and technical service level.
2. Medical quality inspection self-inspection report
xxxx year a series of medical accidents, medical quality, safety alarm bells ringing again. November in the xx county and xx county, there were two cases of medical malpractice in the left and right, the former is a "right leg fracture, left leg surgery", the latter one is a "right leg fracture, left leg surgery", the latter one is a "right leg fracture, left leg surgery". The first one was "right leg fracture, left leg surgery", and the second one was "left side hernia, right side surgery", both patients' surgeons were dealt with due to lack of responsibility, and the "XXX incident" occurred in XXX Hospital, where the relevant doctor was found to be playing online games when the child's condition was deteriorating. The doctor was found to be playing online games. In the wake of the incident, it was determined that there was serious negligence on the part of the medical staff involved. In early November, CCTV reported on the death of XX medical professor XXX at Peking University First Hospital, pointing out that there were a number of irregularities in the medical treatment of trainee doctors who were working independently of each other in the hospital.
The above events once again sounded the alarm of medical malpractice is fiercer than a tiger, the former incident is not forgotten, the latter, these events are worthy of our reference and deep thought. We are medical workers, is the white angel, the future work to have a heart of love and dedication, to have a consistent down-to-earth work. In from now on, starting from themselves. Also recognize the need to pay attention to the quality of medical care, I as a resident combined with their own situation is now summarized as follows:
(1) to do within 30 minutes of the patient's admission to the hospital to check and make the initial treatment.
(2) Emergency, critical and serious patients should be handled immediately and reported to the superior physician.
(3) According to the specified time to complete the medical record writing (24 hours for general patients, critical patients within 6 hours; the first medical record is completed on the shift, emergency patients completed before surgery), rectification.
(4) medical record writing is complete, standardized, and no missing items. Own to strengthen the study of medical record writing. Correct the deficiencies. Word writing is not good, to practice.
(5) Complete blood, urine and stool tests within 24 hours, and according to the condition of the liver, kidney function, and other required specialty tests as soon as possible.
(6) According to the specialty diagnosis and treatment routine to formulate the preliminary diagnosis and treatment plan.
(7) To manage the patient, at least once a day in the morning and afternoon rounds.
(8) according to the specified time and requirements to complete the medical record (consultation, preoperative discussion, preoperative section, transfer out and transfer in, special treatment, the patient's family conversation and signature, discharge section and death discussion and all medical activities should be detailed records).
(9) Changes in the condition of the patients under their care should be reported to the supervising physician in a timely manner.
(10) the diagnosis and treatment process should comply with the provisions of disinfection and isolation, strict aseptic operation, to prevent the occurrence of hospital infection cases. If there is a case of hospital infection, fill in the form and report in time.
(11) The patient's discharge must be approved by the superior physician, should indicate the discharge instructions and account for the precautions.
(12) strictly according to the diagnosis and treatment routine operation, not against the health regulations. In the future, to strengthen the study of health law.
(13) Strengthen doctor-patient communication. Make your own contribution to the harmonious doctor-patient relationship.
Looking back at the past, the size of the medical incident, which is not because of paralysis or not according to the diagnosis and treatment routine operation occurred? Therefore, in the actual work to prevent the slightest step, start from the smallest thing, deal with the unsafe factors in a timely manner, to avoid the occurrence of medical. In fact, to medical safety is not difficult, the key lies in the absence of responsibility. As long as everyone is more careful, as long as the work of a little more serious and responsible attitude, in the post must do their duty, duty must be responsible, no matter where they live, as long as there is a high sense of responsibility and a strong sense of mission, we will be able to avoid the occurrence of medical accidents. In order to further strengthen the medical quality and safety, and effectively establish a "patient-centered" medical service concept, combined with a new round of "three good and one satisfaction", in-depth implementation of the "medical quality Miles", "the clinical application of antimicrobial drugs, special rectification" and other activities, the hospital has carried out a medical safety hidden danger investigation and rectification activities, is now the self-examination of the report is as follows:
First, pay close attention to the quality of medical care, to ensure medical safety
1, strict implementation of the various health care quality and safety management system, strictly in accordance with the diagnostic and treatment process of specialized diseases, clinical work, ensure medical quality and medical safety. The quality and safety of medical care is ensured.
2, the strict implementation of the third-level doctor check-up system, and the condition of the record on the detailed check-up records, condition analysis, medical treatment and the next step of the diagnosis and treatment plan records.
3, the strict implementation of the management system of practicing physicians, no rental, contracting departments, over the scope of the phenomenon of practicing medicine, effectively eliminating the phenomenon of illegal practice of medicine.
4, the strict implementation of the doctor on duty system, do a good job of shift work, critical patients do bedside shift.
5, the implementation of the implementation of the consultation system, difficult or major diseases in a timely manner for consultation, effective protection of medical safety.
6, the quality control physician in each department to strengthen the quality control efforts to improve the quality of medical cases.
7, to strengthen the physician out of the consultation and surgery, intervention and various types of lumens and other invasive medical management.
8, the implementation of difficult cases consultation and discussion system to solve the difficult cases of diagnosis and treatment at the same time, improve the overall academic level of the hospital and at the same time, the lower level of physicians to train and improve their clinical ability and level.
9, every month by the business dean to lead the medical, nursing, pharmacy, hospital sensory personnel of the hospital's pharmaceutical management, hospital sensory management and medical documents and the implementation of the core system to check the problems found to the hospital and timely rectification, and constantly improve the management of medical safety.
Second, strengthen the doctor-patient communication, enhance the understanding of doctors and patients
1, focusing on the humanistic care of patients, improve the doctor-patient communication system, improve the content of doctor-patient communication, such as: communication at the time of admission, inpatient communication, pre-discharge communication, outpatient communication, communication between doctors and nurses.
2, seriously implement the signing of informed consent. For specialized invasive examination and treatment, must be treated by the doctor and the family and the patient for face-to-face communication, the necessity of the diagnosis and examination, indications, possible risks and complications, medical costs, medical need to observe or treatment time to the patient's family to explain, and sign the informed consent.
3, for invasive or interventional operations and treatments, must do a good job of preoperative preparation.
4, for the existence of security risks of patients, such as critical condition, fluctuations in the condition of large changes, mental anomalies, do not cooperate with medical operations, casually out of the patient, must do a good job of explaining the work, and to obtain the cooperation and understanding of the patient's family, and to do a good job of shift handover.
5, the doctor-patient communication about the diagnosis and treatment of the important content of timely, complete and accurate medical records, and signed by the patient or his family to confirm.
6, to strengthen the management of hospital complaints, the implementation of the "first patient responsibility system", and actively resolve conflicts and disputes, safeguard the legitimate rights and interests of doctors and patients to avoid escalation and expansion of conflicts.
Third, improve the medical safety reporting system, to achieve a positive and effective response
1, in strict accordance with the "Interim Provisions for the Reporting of Medical Quality and Safety Incidents", timely, complete and accurate reporting of medical quality and safety incident information. For concealment, omission, misreporting, slow reporting of medical quality and safety event information or poor handling of medical quality and safety events, resulting in serious consequences, according to the law to deal with the relevant responsible persons and be notified.
2, and constantly improve the emergency response plan for medical safety incidents, to achieve a positive and effective response, as far as possible to eliminate the adverse impact of medical safety incidents.
Fourth, there are shortcomings
Through this self-examination, we also found some shortcomings:
1, in the doctor-patient communication, the individual medical staff's awareness is not enough, communication accuracy is not in place. In the future, we have further strengthened the knowledge of doctor-patient communication training to improve the communication skills of medical staff.
2, in the medical writing, individual physicians on the patient's condition changes and treatment measures on the record is incomplete, too simple. We will continue to strengthen the supervision, and effectively avoid medical risks.
4. Medical quality inspection self-examination report
According to the medical quality and safety rectification work rectification requirements. Now on the results of self-examination and the next step in the 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. The patient's condition assessment system is not sound, the risk assessment of surgical patients is limited to preoperative discussion or preoperative summary, has not established a written risk assessment system.
(b) The application of antimicrobial drugs still exists 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.
(C) There are still many problems in the writing of hospitalized medical records.
1, the course of the record of the revised medical advice, positive test results lack of analysis, 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 service consciousness is not strong, the work of the phenomenon of "cold and hard", poor awareness of medical risks, legal awareness is weak, doctor-patient communication skills are not enough, the medical risk is not enough to estimate, resulting in inadequate communication between doctors and patients in place.
(E) the level of professional and technical skills to be further improved, can not well meet the needs of patients, first aid skills need to be further practiced.
(F) the department management is not enough, the problem found after the regular supervision of rectification and implementation, resulting in long-term problems.
Second, the next step in the corrective measures:
(a) to further strengthen the quality and safety education, improve the safety of medical staff, quality awareness.
The medical staff generally pay attention to professional knowledge and pay little attention to the learning of quality management knowledge, 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. 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, medical quality core system, improve the quality of medical staff awareness, safety awareness and awareness of prevention.
(2) to 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, focus on the effectiveness, not a formality, on the problems found in addition to face-to-face explanation, a weekly bulletin, the repeated offenders must be punished through financial penalties, to give disciplinary action.
2, to strengthen the three basic training and assessment, and at the same time, professional knowledge in accordance with the beginning of the year to gradually learn the plan 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 the 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 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 methods and rewards and penalties system, focusing on the monitoring of perioperative prophylaxis to prevent the use of medication, to prohibit the abuse of antibiotics.
(C) to further strengthen the professional ethics education in the department, and effectively improve the level of service of medical staff.
According to the Ministry of Health, "medical ethics code and implementation of medical personnel," as well as the requirements of the group education activities, medical ethics education for medical personnel. Cultivate a modest and cautious, 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, really set up a "people-oriented, patient-centered" concept, to really do the patient as their own relatives, do not seek self-interest.
(D) continue to strengthen the doctor-patient communication skills training, for the patient admission, medical intervention, the patient call, surgery, special examination, the condition of the change of the situation of the doctor-patient communication skills training, in order 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.
5. Medical quality inspection report
In accordance with the County Food and Drug Administration, the County Health Bureau of the relevant requirements, in order to strengthen the quality management of medicines and medical devices, to protect the safety of medical care, I focus on the whole hospital medicines, medical devices, a comprehensive self-inspection, the specific situation is reported as follows:
A, organization Leadership, improve the system
The hospital leadership attaches great importance to the establishment of a dean as the head, the director of each department as a member of the safety management organization, the management of drugs, medical equipment safety into the hospital's top priority. Strengthen the leadership, strengthen the responsibility, enhance the awareness of quality responsibility.
The hospital has established, revised and perfected a series of drug and medical device related systems such as drug and medical device purchase management system; drug and medical device warehousing system; disposable medical supplies management system; supervision and management system of adverse events of medical devices; medical device storage, maintenance, use, repair system, and so on, in order to ensure the safe and smooth implementation of the clinical work of the hospital system.
Second, the investigation situation
Combined with the higher inspection and our hospital self-inspection, found the following problems:
1, part of the department of temperature and humidity meter is damaged, missing, temperature and humidity meter placement, fill out the non-standardized.
2, the pharmacy refrigerated cabinets show greater humidity and not dehumidified; refrigerated cabinets put private food, part of the storage conditions below 20 ℃ drugs are not stored in the refrigerated cabinets; traditional Chinese medicine pharmacy piles of western medicines and paper shells, miscellaneous objects are not cleaned up in a timely manner.
3, surgery, internal medicine, traditional Chinese medicine treatment room a few cotton swabs, infusion bags expired without timely treatment; treatment room part of the spare drug placement is not standardized, not away from the ground away from the wall; first aid cabinet cover did not fill in the expiration date of the drug.
4, the original gynecology treatment room a few drug debris is not timely cleaned.
5, part of the medicine, mechanical company qualification expired, incomplete information.
In response to the above problems, the hospital attaches great importance to the hospital, immediately held a general meeting of all hospital staff, the above problems were notified, the implementation of the accountability system, and immediate rectification.
Third, corrective measures
1, to further increase the knowledge of drug and medical device safety publicity, the implementation of the relevant system, to improve the hospital's awareness of the responsibility of drug and medical device safety.
2, to increase the hospital drugs, medical equipment safety daily inspection, supervision frequency, timely investigation of drugs, medical equipment safety hazards, firmly establish the "safety first" consciousness, service patients.
3, in order to ensure the quality of purchased drugs, medical equipment and the use of safety, to eliminate unqualified, expired drugs, medical equipment use. The hospital has implemented a special person on the purchase of drugs and medical equipment to have the conditions and qualifications of the supplier to make strict provisions.
4, in order to ensure that the incoming drugs, medical equipment, legal and quality, the hospital carefully implemented to ensure the safe use of medical equipment.
5, do a good job of daily storage. In order to ensure the quality of drugs and medical devices stored in the warehouse, we have arranged for specialized personnel to do a good job in the daily maintenance of drugs and medical equipment.
6, the implementation of the relevant sections of personnel, strict inspection, replacement of the problem temperature and humidity meter, and improve, fill in the records.
Fourth, the future work intends
Continuously improve the relevant systems, the implementation of the "one job, two responsibilities" system, pay close attention to all the details. Active cooperation with higher authorities, seriously complete the tasks issued by the higher authorities, continue to consolidate the hospital drugs, medical equipment safety achievements, *** with the creation of drugs, medical equipment, a good atmosphere, in order to build a harmonious society to make a greater contribution.