Medical Quality Self-Investigation Report (Selected 5)
In a flash, time flies like electricity, the work has come to an end, review the work of this period of time there are many problems, take immediate action to write a self-inspection report. But you know how to write a good one? The following is I help you organize the medical quality self-examination report (selected 5), only for reference, welcome to read.
Medical quality self-examination report 1
In order to strengthen the medical quality management of my hospital, to protect medical safety, combined with the county health bureau of my hospital medical quality work inspection results of my hospital organization of the relevant personnel on the hospital again on the medical quality management work to start the self-check, now on the existence of the problem and the next step of rectification measures are stated as follows:
A. Existing problems.
1, the new medical quality inspection standards lack of understanding
The hospital in the medical quality management in the quality management is not fully use of quality management tools, PDCA in the medical quality management of the use of the rate is not high, on the statistical analysis of the absence of bar charts, fishbone charts, etc., can not adequately reflect the data changes.
2, fire to be further strengthened
Fire safety supervision and management department supervision is not in place, part of the dry powder fire extinguishers are not regularly inspected, the inspection is not recorded in a timely manner after the fire, fire knowledge and fire awareness needs to be further improved.
3, medical quality management needs to be further strengthened
(1), the core system and the implementation of medical record writing standards need to be strengthened, part of the staff of the core system to grasp and understand the core system is not enough, can not memorize the core system.
(2), poor surgical management, the lack of unplanned re-operation related knowledge training, lack of emergency surgery management, "three-step verification" is not fully implemented.
(3), the medical department, the nursing department and other relevant departments of the supervision of the traces of insufficient.
(4) The referral process for emergency patients is not clear, and there is a lack of emergency equipment and poor first aid skills among the staff.
(5), did not establish a catalog of high-risk diagnostic and therapeutic items, and insufficient awareness of high-risk items in the hospital. There is no authorization for practitioners engaged in high-risk projects.
4, hospital infection management still needs to be strengthened
(1), hand hygiene training needs to be strengthened, there is no training program, the staff of the seven-step hand washing is not a firm grasp of the hand, hand hygiene publicity map less.
(2), the hospital sensory testing program is not targeted, the key links, key departments of the risk assessment is not perfect.
(3), the lack of laboratory personal protective equipment, no eyewash, incomplete labeling, the risk of occupational exposure, the awareness of occupational exposure follow-up is not in place.
5, clinical drug management still need to be further strengthened
(1), the management of poisonous and anesthetic drugs need to be improved. Poison and anaesthetic prescription is not standardized, not in accordance with the provisions of the registration, poison and anaesthetic drug management personnel are not qualified, poison and anaesthetic drug safekeeping office security facilities are lacking.
(2), the use of antibiotics unreasonable phenomenon is relatively obvious, no antimicrobial graded use of directory; no doctor training, assessment records, no doctor antimicrobial graded use of authorization, perioperative prophylaxis, the use of antimicrobials do not comply with the provisions of the; antimicrobial drug use ratio exceeds the standard.
(3), there are no indications for the use of drugs, prescription transfer audit has missed signatures, the ability to review the rational use of drugs on the prescription is low.
6, auxiliary checks and laboratory tests
(1), laboratory tests can not fully meet the diagnostic needs of critical situations.
(2), the laboratory quality control program is incomplete
(3), to do invasive tests before the patient did not fully explain, and to obtain the patient's consent to answer recognized.
Second, corrective measures
1, the establishment of sound rules and regulations to strengthen hospital management
sound system to strengthen the responsibility to conscientiously implement all levels of the checkup system, reporting system. Clinical departments should strengthen the first physician responsibility system, consultation system, preoperative discussion system, difficult case discussion system, death case discussion and other core system implementation. Further improve the management system to strengthen the standardized management of the hospital.
2, increase the supervision and inspection efforts to ensure the implementation of the core system
(1), to strengthen the health supervision and inspection efforts, and effectively improve the patient's medical environment.
(2), the medical department to further strengthen the quality of inspection and running medical records inspection work, this work to improve the quality of medical care is a very good measure, but focus on the effectiveness, not a formality, the problems found in addition to face-to-face explanations of the repeated offenders must be punished through financial penalties, to give discipline.
(3), to strengthen the three basic training and assessment, we must continue to improve the assessment methods, serious assessment discipline, pay attention to the effectiveness of the assessment, from time to time on the section staff to carry out random checks. The person in charge of the department should pay attention to the three basic training, and often speak to the medical staff about the importance of the three basic learning, to ensure that a monthly assessment of the department, which is essential to improve the technical level of medical staff.
(4), to strengthen the management of the quality of the case
To further improve the relevant systems and medical records inspection standards, to develop incentives and penalties, to ensure that the timely filing of hospitalized medical records and the safe flow.
(5), to further strengthen the monitoring of hospital infections should be further in the hospital infection case monitoring, sterilization effect monitoring, environmental hygiene monitoring and other work up and down, strict implementation of the hospital infection management system, to do the work in detail, can not cope. It is necessary to further increase the training and publicity of hospital infection knowledge, so that each medical staff should recognize the importance of hospital infection control, consciously abide by the aseptic operation techniques, and do a good job of personal control links. Play the role of departmental hospital infection control team, with the Hospital Infection Office to actively carry out the work, to put an end to the underreporting of hospital infection events.
3, to further strengthen the management of the use of antibacterial drugs
(1), according to the Ministry of Health "to further strengthen the management of the clinical application of antibacterial drugs" notification spirit, to develop the specific implementation of our hospitals, and the system of rewards and penalties, focusing on the monitoring of perioperative prophylactic use of drugs. To further implement the antimicrobial drug hierarchical management system, set prescription authority for doctors to ensure the implementation of the system. To ensure the rational use of antimicrobial drugs.
(2), in strict accordance with the "poisonous and anesthetic drugs management measures" to strengthen the management of poisonous and anesthetic drugs, the Pharmaceutical Affairs Management Committee from time to time to check the management of poisonous and anesthetic drugs.
(3), to strengthen the responsibilities of the Pharmaceutical Affairs Management Committee, to ensure the safety of patients' clinical use of medication hospital pharmacy committee to conscientiously fulfill their responsibilities, strict implementation of the "Interim Regulations on Pharmaceutical Affairs Management in Medical Institutions", to strengthen the training, supervision and management, in order to ensure that clinical use of medication, medical materials and other qualified quality, safety, and in line with the requirements of clinical use. Further improve the monitoring of adverse drug reactions and report them on time. Standardize the construction of the pharmacy, timely inventory and report the near expiration date of drugs.
4, to meet the psychological needs of patients, close doctor-patient relationship, reduce the occurrence of doctor-patient disputes, and create a harmonious environment
Health care workers must be dressed neatly, kindly, energetic, and take the initiative to introduce themselves to the patient is its sub-doctors or nurses, so that the patient gets a good impression of the health care personnel have a sense of trust and a sense of reliance, so that the patient's emotional stability, family satisfaction and peace of mind. Emotional stability, family satisfaction and peace of mind, in the process of diagnosis and treatment in order to take the initiative to cooperate, the establishment of a proactive and cooperative doctor-patient relationship.
Medical quality self-examination report 2According to the medical quality and safety rectification work rectification requirements, my department on the medical quality of a comprehensive inspection. Now on the results of self-examination and the next step of rectification measures reported as follows:
First, there are problems:
(a) certain medical core management system there is not enough to implement. Individual medical staff 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 irregularities, 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 "cold and hard"
phenomenon, medical risk awareness is poor, the legal awareness is weak, the doctor-patient communication skills are not enough, the medical risk is not enough to estimate, resulting in the doctor-patient communication is not in place.
(E) professional and technical level to be further improved, can not well meet the needs of patients, first aid skills need to be further practiced.
(F) department management is not enough, the problem found after the regular supervision of rectification and implementation, resulting in long-term problems.
The next corrective measures:
(a) further strengthen the quality and safety education, improve the medical staff's safety, quality awareness.
The medical staff generally exists to pay attention to professional knowledge and despise the learning of quality management knowledge, the lack of quality management knowledge, quality awareness is not strong, so it can not consciously and actively apply the quality requirements in 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, while the professional knowledge in accordance with the beginning of the year to learn
plan to gradually learn 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 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 and 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 prohibit the abuse of antibiotics appear.
(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's admission, medical intervention, patient call, surgery, special tests, changes in the condition 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.
Medical quality self-examination report 3 A medical quality management Our hospital pay close attention to the quality of service, to prevent medical errors, according to the law, civilized practice. The hospital set up to Zhang Jiyue, vice president of the leading group of medical quality management, regular sampling of prescriptions, medical records, timely feedback to the relevant responsible person, the whole hospital to monitor the quality of medical care. A variety of single disease quality control to meet the city and district standards. Two, medical instruments Strictly abide by the "basic specification for medical records writing" in the requirements for the patient to do objective, true, accurate, timely and complete writing of all medical instruments. Three, rules and regulations Our hospital to improve and implement a series of rules and regulations, improve the management system, including 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 place to find out more about the company's services, and to learn more about the company's products and services. Our hospital strictly abide by the health insurance system, the organization of the whole hospital medical staff repeatedly and seriously study the health insurance related policies, and carried out the assessment work, will be assessed and personal interests of the distribution of the results linked. Fourth, the basic drug system For the examination and treatment of patients in the clinic or hospitalized patients, the hospital 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 do Reasonable inspection, reasonable use of medication, reasonable treatment, reasonable fees, can use low-priced drugs do not use high-priced drugs, and effectively reduce the burden of medical costs of farmers. The stock of drugs in the pharmacy reaches more than 90% of 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. The company's products and services are available in a wide range of colors and sizes, and are available in a wide range of colors and sizes. Fifth, 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 the quality of service, shorten the average length of stay of patients, strict control of 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, medical support work in the countryside, to improve the level of expertise of the front-line health care personnel, improve the structure of knowledge, update the latest professional dynamics, are of great help. VII, 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, the professional development of the lack of energy 2, senior Chinese medicine practitioners for the computer mastery is not good, failed to realize all the electronic prescription, the improvement of outpatient coordination there is a certain resistance. There is a certain resistance to the improvement of outpatient coordination. 3, found that individual physicians have outpatient prescription failure phenomenon, including the prescription format is not qualified, outpatient antimicrobial use ratio of more than 20%, and so on. Eight, the direction of future efforts I must take the 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 medical services and technical services. The quality of medical services and technical service level is constantly improved. In order to conscientiously implement the Provincial Department of Health "on the province to carry out medical service quality management efficiency year activities of the views", our hospital has held a number of relevant meetings, the implementation of the layers, set up a medical quality management leading group, responsible for the level by level, to improve the quality of medical management system, the implementation of the rules and regulations and technical specifications, and strive to improve the level of service of the hospital, to ensure the quality of medical care, better for the people. medical quality, and better serve the health of the people. For the current situation of our hospital, according to the "Linyi City Hospital Medical Quality Inspection Standards", a serious self-examination, to find out the current problems of our hospital, in order to timely and effective correction, focusing on the following aspects of the development of relevant measures: A further improve the business quality of medical personnel: Seriously study the relevant laws and regulations, systems and norms and post Do love and dedication, passionate service. In the first half of the hospital invested more than 10,000 yuan, the number of personnel sent to the provincial and municipal hospitals for further study, there are personnel to participate in the provincial and municipal gynecology, pediatrics, maternal and child health care study sessions. At the same time in order to improve the overall level of medical personnel, comprehensively improve the quality of medical personnel, every Friday regularly organize business learning, regular organization of the assessment, in order to ensure the quality of learning, the examination results and personal economic benefits linked to greatly mobilize the front-line medical personnel to learn the enthusiasm. Through the study for each medical staff to master the basic theory, basic knowledge and basic skills to lay a good foundation. Each medical staff have done to technical excellence, dedication to learning, and actively enterprising, in the work and learning to continuously improve the technical level. In the month of January, the on-the-job workers*** wrote and published a paper, published a paper in the provincial publication, the municipal level. And in the study does not forget to educate all medical personnel in the work to reflect the people-oriented, respect, care, convenience, service to the patient's humanistic spirit. So that the majority of health personnel firmly established the concept of wholeheartedly serving the people, to establish a good moral image and professional image. In accordance with the twelve-word civic code of ethics of "patriotism and law-abiding, unity and friendliness, diligence, thrift and self-improvement, dedication and devotion", effective measures have been taken to set off a climax of learning and publicity activities. Let each patient feel in our hospital as if to their own home, feel the civilized wind of modern hospitals. Two improve and carry out various medical technology: Our hospital is thin, clinical work is carried out relatively late, in the face of this status quo. The leadership team did not simplify, but strictly quality control, comprehensively ensure that the construction of business units in line with the basic standards of the state or province, and the strict implementation of various diagnostic and treatment technology operation norms, to ensure that the medical technology is safe and effective. In response to the current situation of antibiotic abuse, the leading group of medical quality management did not go with the flow, but strictly regulate the use of antibiotics, control hospital infections, and strive to reduce complications. Three make full use of the existing equipment, the acquisition of necessary medical equipment, comprehensively improve the level of diagnosis and treatment: Make full use of the existing `equipment, so as not to cause a waste of resources. In order to continuously improve the level of medical care, to meet the needs of clinical care, the beginning of the hospital leadership team based on a high starting point, high standards, strict requirements, one step, raise funds from various sources million yuan to buy a semi-automatic biochemical analyzer, anesthesia respiratory machine, urinalysis analyzer, vertical autoclave and other medical equipment. The existing equipment timely maintenance and repair, to ensure normal operation, standardized operation, inspection and treatment effects of safe and reliable, accurate and credible measuring instruments. Four to establish sound rules and regulations, strict implementation of the operating procedures: The implementation of standardized management is to improve the quality of service is the key, we have always grasped not to let go. First of all sound system to strengthen the responsibility. The president seriously implement the system of room inspection, administrative duty system. The medical department to strengthen the collective review of the film system, clinical patient follow-up system, laboratory indoor quality control system. Clinical departments strengthen the first physician responsibility system, resident hourly responsibility system, three-level checkup system, consultation system, preoperative discussion system, difficult case discussion system, death case discussion system and other systems. At the same time seriously implement the provisions of surgical grading management, strict control of surgical indications, strict operation, postoperative observation. In the first half of the year **** completed gynecology, obstetrics surgery cases, without a single case of error. The improvement of medical quality, but also brought good economic and social benefits, clinical business income than the same period last year increased. Five to ensure the quality of drugs, reagents and medical materials, to ensure that the patient treatment is safe and effective: Ensure the quality of drugs, reagents, medical materials, to achieve safe and reliable, in line with the requirements of clinical use, the strict implementation of the "Interim Regulations for the Management of Pharmacological Affairs in Medical Institutions", to improve the monitoring of adverse drug reactions. The management of toxic drugs for medical use, x-ray drugs, radiopharmaceuticals and narcotic drugs is strengthened in accordance with the law. And set up a drug and material purchase management committee, to take the centralized bidding procurement, from the source to eliminate the procurement of unethical practices. Six to improve the hospitalization environment, to provide patients with good medical conditions: According to the medical management leading group put forward by the spirit of humanism everywhere, all for the convenience of the patient service requirements. Our hospital at the beginning of this year on the environment of our hospital to do the overall planning, investment of 10,000 yuan to remodel the wards and treatment rooms as well as the environment of the hospital, to achieve the environment of elegant, neat and clean for the patients to provide a convenient and high-quality, warm and comfortable diagnosis and treatment and rehabilitation environment. We are medical workers, is the white angel, the future work to have a love and dedication to the heart, to have a consistent down-to-earth work. In the start from now, start 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 (ordinary patients 24 hours, critical patients within 6 hours; the first medical record completed on the shift, emergency patients completed before surgery). (4) medical record writing is complete, standardized, and no missing items. One should strengthen the study of medical record writing. Correct the deficiencies. Writing is not good, to practice writing. (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 stays a little more careful, as long as the work a little more serious and responsible attitude, in the post must do their duty, do their duty must do their duty, no matter where they live, as long as there is a high sense of responsibility and a strong sense of mission, will be able to avoid the occurrence of medical accidents.