Health hospital medical safety self-study report
As the civilization of individuals continue to improve, the report is more and more closely related to us, write a report to pay attention to the content of the integrity of the report. So do you know the standard formal report format? The following is my health center medical safety self-inspection report for everyone, just for reference, I hope it can help you.
Health hospital medical safety self-inspection report 1
Medical safety hidden danger rectification self-inspection report of my hospital according to the City Health Bureau issued on the requirements of medical safety hidden danger rectification activities, seriously organize the majority of workers to learn the spirit of the activities, according to the requirements of the hospital in all aspects of the work of the special rectification activities. Through the rectification activities carried out since, now the rectification of our hospital rectification problems and rectification measures reported as follows:
1, problems:
(a) the quality of medical care problems
1. outpatient department problems
According to the management of outpatient emergency and clinic department requirements, our hospital outpatient The emergency department has not been set up separately, there is no fixed business skills strong outpatient and emergency staff. Outpatient and emergency physicians are not highly licensed, and there are cases of unlicensed and illegal practice of medicine. Some of the medical staff do not have high business skills, are not able to skillfully master and apply some common first-aid equipment, and are not skilled enough to master some basic first-aid techniques. The cooperation between the various departments is not close enough, and there is not enough collaboration between the departmental staff.
Medical instruments are not standardized. Outpatient prescription writing is not standardized, the elements are incomplete, the dosage and usage are not detailed, the application of antibiotics is not standardized, there is irrational use of drugs. Outpatient hospitalization medical records are too simple, not able to strictly regulate the writing of hospitalization cases. The quality management of hospitalized cases is not in place, and some medical personnel do not write cases in a standardized and timely manner. All kinds of records are not standardized, and the writing of records of conversation with emergency and critical patients, rescue records, records of discussion of difficult cases, and records of discussion of dead patients are not standardized, and the writing requirements are far from meeting the requirements of standardization of the quality of writing of medical documents. The registration of various outpatient logs is incomplete, discontinuous and incomplete. Some of the medical systems and core systems are incomplete and imperfect. To be with the further establishment, sound, the implementation of the relevant departments of the system, especially the township hospitals continue to improve the core system of the implementation of the system is not in place, part of the system is not in line with the needs of the current stage of hospital management.
2. Nursing problems
The establishment of the nursing system is incomplete and imperfect. The previous nursing system is to outpatient system management as a starting point for the establishment of up, since the inpatient building put into use, the original system has not been enough to adapt to the requirements of the current management, now need to be combined with the management of the inpatient department of the actual situation of the establishment of the relevant standard system.
Nursing management organization system is not complete. Not in accordance with the provisions of the Nursing Regulations system, the implementation of relevant nursing management, not the implementation of the target management responsibility system. Since the hospital inpatient department put into use since the nursing management department is not in accordance with the function and task of the township health center to establish a perfect nursing management system, the duties of each position is not clear, there is a mutual shirking of responsibilities in the work. Nursing human resource management is not complete, not combined with the actual establishment of the unit's nurse management system. There are no clear requirements for the qualification, technical ability and technical standards of nurses at all levels and in all categories, and they have failed to establish a sound mechanism for the assessment of nurses' level and performance. According to the hospital nursing staffing standards, ward nurses and beds do not meet the required standards.
Nursing work assessment standard establishment is incomplete and imperfect. Regular assessment of nursing work is not timely, and is a mere formality. Not strictly in accordance with the "basic norms for case writing" writing nursing instruments, nursing instruments are not standardized, writing quality is not high. All kinds of registration is incomplete, such as disinfection records, detention records, emergency and critical patient rescue records, shift handover records.
The concept of sterile technology is not strong, and the operation still needs to be further improved. Failure to effectively establish the nursing skills operation norms and standards, part of the nursing staff skills operation is not standardized, the destruction of disposable items is not thorough, not standardized. Outpatient clinics, inpatient departments and other departments of poor hygiene, there is a hidden danger of cross-infection, quilt covers, bed sheets are old, the glass is not clean, cleaning is not timely.
3. Problems in the work of the pharmacy
Pharmacy drug management system is not complete. Poisonous, narcotic, dramatic drug management system is not in place, the account records are not standardized, the management of hidden dangers. Drug management work is not in place, the expiration date of invalid moth-eaten drugs still exist.
The hospital is actually engaged in the work of drug dispensing personnel are non-pharmacy professional and technical personnel, by other professional and technical personnel qualified by the Pharmacy and Inspection Bureau of the training to engage in the dispensing of pharmaceuticals. On the relevant drug dispensing drug knowledge is not enough to understand, prescription dispensing is not strict, from time to time there are unqualified prescription dispensing occurs. Part of the dispensing staff is not strong sense of responsibility, there is a mix of wrong drugs occurring.
(B) service attitude problems
The outpatient staff service attitude is not good, the patient sometimes react, service attitude, service consciousness, service quality is poor, medical services in the existence of cold, touch, hard, top and other problems, service attitude to be further improved.
Nursing staff service quality is not high, and fails to reflect the humanized service. Provide basic care and level of care measures are not in place, the care of hospitalized patients to stay in the primitive stage. Part of the medical staff medical service quality is not high, poor service attitude, patients reflect strongly. Some nurses are not responsible enough for their post duties, and the implementation of the three-checking and seven-checking system is not in place, and there are hidden medical dangers. Nursing error reporting and management system is not in place, the patient's observation is not in place, the nurse is not able to take the initiative to report some nursing adverse events.
4. Pharmacy staff
Service attitude needs to be further improved. Staff service awareness is poor, bad attitude, failed to establish a patient-centered pharmacy management service model. To the patient service words cold, poor attitude, there and the patient quarrel situation, the patient reaction is strong. Service attitude needs to be further improved.
(C) cadres and workers work style, mental outlook of the problems
Some medical workers get by, enterprising, sense of responsibility, initiative is not strong, the need to further enhance the sense of responsibility for the work, a sense of urgency, a sense of crisis, to enhance the awareness of the service, improve the way of service, improve the relationship between doctors and patients, so that the masses of the style of the health care institutions of the public satisfaction has increased significantly. Part of the medical staff poor mental outlook, not wearing work clothes during the work period, do not wear a work permit, off duty, chatting, mental depression can not be able to work in a vigorous state of mind into the medical work.
In order to strengthen the management of medical safety, to prevent the occurrence of various types of accidents, to protect people's lives and property safety, our hospital in accordance with the requirements of the program of activities of the year of medical quality management, the town of medical safety work carried out a serious self-inspection, is now self-inspection report is as follows:
A self-inspection
Through the self-inspection of the town, we can see that the town of the town is a very important place for the safety of the people. p>
Through the self-examination, *** investigation of the problem 5, the development of corrective measures 5, of which the recent need to solve the 4, gradually solve 1.
1, the lack of health center personnel, a body with multiple jobs, resulting in a more prominent phenomenon of unlicensed.
2, individual medical staff can not memorize the core medical system, in practice, outpatient log, prescription writing, case writing, technical operation is not standardized.
3, individual medical staff did not strictly implement the shift handover system, sometimes there is no shift handover record.
4, prevention and protection work in the children's vaccination table, thin, card, book is not sound.
5 three basic three strict training time is not enough, not strong enough.
Second, corrective measures
1, for the existence of the problem of unlicensed. I hospital before the arrangement of new professional induction personnel, temporarily take a practicing certificate of . Medical personnel to bring good unlicensed personnel on duty to ensure medical safety.
2, for individual medical staff can not memorize the core medical system problems. We organized in the near future to focus on medical staff to study, seriously implement the job responsibility system, 13 medical core system, diagnosis and treatment standards and nursing operation norms, in order to ensure the safety of medical care.
3, for individual medical personnel do not implement the shift handover system there is a problem. After the discovery of the suspension of the duty fee, the warning and in accordance with the hospital rules to be severely punished.
4, for the defense and security work problems. Units in the serious shortage of staff, to overcome the difficulties, increase efforts to increase personnel, while further improving the prevention and protection of software, the establishment of a sound and qualified form book and card book.
5, for the three basic three strict training time is not enough, the strength of the problem. First of all, we must strengthen the leadership, raise awareness, develop plans, pay close attention to the three basic and three strict training, seriously organize the study of professional knowledge, improve the level of business, pay attention to talent training.
Third, the establishment of the organization
In order to ensure the management of medical safety in the health hospital, the establishment of a leading group:
Leader:
Deputy Leader: members: the Office of the medical department. Director:
Phone:
Health hospital medical safety self-examination report 3In order to improve the quality of medical services and technical service level, according to the Shandong Provincial Department of Health, "on the annual inspection of medical institutions notice", my community health service center against the "Medical Institutions Management Regulations Implementing Rules" to carry out a rigorous self-examination and self-correction work. Now the relevant self-examination report is as follows:
First, the leadership attaches importance to the strict organization
My community health service center received the "notice on the annual inspection of medical institutions", the center leadership attaches great importance to the work of the self-examination and held a meeting on the deployment of strict. At the meeting, the establishment of the Wang Houzeng as leader, Ma Hong as deputy leader, the relevant business departments responsible for members of the self-checking leading group, the business departments in accordance with their respective division of labor, strictly against the "Rules for the Implementation of the Regulations for the Administration of Medical Institutions" carried out a serious and detailed self-checking and self-correcting work, and achieved significant results.
Second, the basic situation of self-check
(a) institutional self-check: unit full name of the Lichang District Xiangtan Road Street HaiMedica Community Health Service Center, the nature of the non-profit, located in the Lichang District, Chongqing, Middle Road, No. 932-5-9; legal representative: Wang Houzeng; the main person in charge of: Ma Hong. With the Lichang District Health Bureau issued a "medical institutions license", license number:, valid until December 31, 20xx. My Community Health Service Center has implemented strict management of the "Medical Institution Practice License", and has never altered, bought and sold, transferred or rented. Existing observation beds 3, diagnosis and treatment subjects are preventive health care, general diagnosis and treatment section, gynecology, surgery, internal medicine, stomatology, Chinese medicine, medical laboratory, rehabilitation medicine, medical imaging; business room area of 1000 square meters.
Approved subjects: my community health center did not publish medical advertisements in any form, in strict accordance with the approved scope of business and services to carry out external activities, not beyond the approved scope of registration, and comply with the relevant laws, administrative regulations and the State Council administrative department of health care to develop medical technology routines and resuscitation and referral system, all the subordinate departments have no internal and external contracting or leasing, and never one-sided pursuit of economic benefits. It has never carried out identification of the sex of the fetus and termination of pregnancy in violation of the law in pursuit of one-sided economic interests.
(2) personnel self-examination: my community health center existing chief physician, deputy chief physician, two attending physicians, three physicians, a licensed pharmacist, a surveyor, six nurses, an accountant. My community health service center has never more than the scope of registration to carry out practice activities or illegal issuance of "medical certificates"; never used without the qualification of licensed physicians, nurses licensed personnel or a certificate of registration of multiple locations of physicians engaged in medical activities, but also never used the practice of physician assistants to practice alone; belonging to the medical and nursing staff are licensed, and set up in the hall of the supervision column to the outside world.
(C) improve the quality of service: in accordance with the relevant provisions of the health administrative departments, standards to strengthen the management of medical quality, the implementation of medical quality assurance program; regular inspection, assessment of the rules and regulations and all levels and types of personnel job responsibility system implementation and implementation, to ensure medical safety and quality of service, and constantly improve the level of service.
(D) the management of hospital cross-infection: the establishment of a hospital cross-infection management leading group, composed of Wang Houzeng, Ma Hong, Huang Jie, etc., the leading group of personnel have obtained the certificate of induction. Frequent education and training of relevant personnel, the establishment and improvement of the management of medical waste disposal, nosocomial infection and disinfection management, waste leakage treatment program and other relevant rules and regulations, there are people on the source of medical waste, type, quantity, etc. complete record, regular disinfection of key departments and parts of the disinfection effect of the monitoring, prepared disinfectant labeling is clear, complete and standardized.
(e) solid medical waste disposal: all medical waste is classified and collected, according to the provisions of the time of temporary storage of dirt with warning signs, dirt containers are sealed, anti-stabbing, temporary storage of dirt to achieve the five prevention of medical waste transportation and transfer for a person in charge of and have a signature record.
(F) disposable medical supplies processing: all disposable medical supplies after use to do soak disinfection, destruction of the type of medical waste treatment station by the Jiecheng collection, harmless disinfection, and has a detailed record of medical waste handover, no resale, give away and so on. All operators are trained and have specialized protective facilities and equipment.
(VII) epidemic management and reporting: my community health center has established a strict epidemic management and reporting system, which provides for a person in charge of epidemic management, epidemic register content is complete, the epidemic report card fill out the standard, the epidemic report to carry out a monthly self-check processing, no omission or late reporting occurs.
(H) drug management self-examination: after investigation of my community health center has never used fake, expired, expired and prohibited drugs.
Third, there are shortcomings
First, due to insufficient funding, some medical equipment can not be timely maintenance or update, to a certain extent, affecting the in-depth development of related business, professional development of the lack of energy; Second, by the establishment of the limitations of the personnel, tight, heavy workload, to the provincial medical institutions to further training opportunities are not much, the knowledge of the update of the long cycle, to a certain extent, affecting the development of the community health center. The long cycle, to a certain extent, affects the level of service to a higher level to improve.
Fourth, the future direction of efforts
I community health centers must be the annual inspection 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, innovative, and constantly improve the quality of medical services and technical services. The quality of medical service and technical service level is constantly improved.