Inadvertently, a period of work ended, and the work problems that existed in the past period of time are worth summarizing. Let's learn to write a self-inspection report together. I believe many people will find it difficult to write a self-inspection report. The following is the quality self-inspection report (5 selected articles) I collected for you. Welcome to reading. I hope you will like it.
Quality self-inspection report 1 In order to strengthen the medical quality management of our hospital and ensure medical safety, our hospital organized relevant personnel to conduct self-inspection on the medical quality management of our hospital again in combination with the inspection results of the county health and family planning bureau. The existing problems and the next rectification measures are described as follows:
First, the existing problems:
1, lack of understanding of the new medical quality inspection standards.
The hospital did not make full use of quality management tools in medical quality management, and the utilization rate of PDCA in medical quality management was not high, and there was no histogram and fishbone diagram for statistical analysis, which could not fully reflect the data changes.
2. Fire fighting needs to be further strengthened.
The supervision of the fire safety supervision and management department is not in place, and some dry powder extinguishers are not regularly inspected and not recorded in time after inspection. Fire fighting knowledge and awareness need to be further improved.
3. Medical quality management needs to be further strengthened.
(1), the implementation of the core system and medical record writing norms needs to be strengthened, and some personnel do not have enough grasp and understanding of the core system to remember.
(2) Operation management is not in place, lack of knowledge training on unplanned reoperation, lack of emergency operation management, and "three-step verification" is not fully implemented.
(3) The medical department, nursing department and other departments have insufficient supervision traces.
(4) The referral process of emergency patients is not clear, the first-aid equipment is lacking, and the relevant personnel have poor first-aid skills.
(5) The catalogue of high-risk diagnosis and treatment projects has not been established, and the understanding of high-risk projects in our hospital is insufficient. Employees engaged in high-risk projects are not authorized.
4. Hospital infection management still needs to be strengthened.
(1), hand hygiene training needs to be strengthened, there is no training plan, the staff can't grasp the seven-step washing method firmly, and there are few hand hygiene publicity pictures.
(2) The hospital infection detection plan is not targeted, and the risk assessment of key links and departments is not perfect.
(3) The laboratory lacks personal protective equipment, no eye washer, incomplete identification, occupational exposure risk and insufficient understanding of occupational exposure follow-up.
5. Clinical pharmacy management still needs to be further strengthened.
(1), narcotics management needs to be improved. The prescription of narcotic drugs is not standardized, not registered according to regulations, the management personnel of narcotic drugs are unqualified, and the safety facilities of narcotic drugs storage places are missing.
(2) The irrational use of antibiotics is obvious, and there is no catalogue of graded use of antibiotics; There is no record of doctor training and assessment, no doctor authorized to use different levels of antibiotics, perioperative prevention, and the use of antibiotics does not meet the requirements; The proportion of antibacterial drugs used exceeded the standard.
(3) Whether there are indications for drug use, there are omissions in the review of prescription dispensing, and the ability to comment on rational drug use of prescriptions is low.
6. Auxiliary inspection and laboratory inspection
(1), the laboratory examination items can't fully meet the needs of emergency diagnosis.
(2) The laboratory quality control project is incomplete.
(3) Before the invasive examination, the patient was not fully explained, and the patient agreed to answer.
Second, the rectification measures
1, establish and improve rules and regulations, and strengthen hospital management.
Improve the system, strengthen the responsibility, and conscientiously implement the system of rounds and reports at all levels. Clinical departments should strengthen the implementation of the core systems such as the first-visit physician responsibility system, consultation system, preoperative discussion system, difficult case discussion system and death case discussion system. Further improve the management system and strengthen the standardized management of hospitals.
2. Strengthen supervision and inspection to ensure the implementation of the core system.
(1), strengthen health supervision and inspection, and effectively improve the patient's medical environment.
(2) The Medical Department should further strengthen the work of quality ward round and medical record examination, which is a good measure to improve the medical quality, but it should pay attention to actual results and not become a mere formality. In addition to explaining the problems found in person, repeated offenders must be punished financially.
(3), strengthen the three basic training and assessment, to constantly improve the assessment methods, serious assessment discipline, pay attention to the effectiveness of the assessment, and conduct random checks on department personnel from time to time. The person in charge of the department should pay attention to the training of "three basics", often tell the medical staff the importance of learning "three basics" and ensure the internal examination once a month, which is very important to improve the technical level of medical staff.
(4) Strengthen the quality management of medical records.
It is necessary to further improve the relevant systems and medical record inspection standards, and formulate reward and punishment measures to ensure the timely filing and safe circulation of hospital medical records.
(5) To further strengthen the monitoring of hospital infection, great efforts should be made in the monitoring of hospital infection cases, disinfection and sterilization effect and environmental sanitation. , and the hospital infection management system should be strictly implemented, the work should be meticulous, can not cope with. It is necessary to further strengthen the training and publicity of hospital infection knowledge, so that every medical staff can realize the importance of hospital infection control, consciously abide by aseptic operation technology and do a good job of personal control. Give full play to the responsibilities of the department's hospital infection control team, cooperate with the hospital feeling office to actively carry out the work, and put an end to the omission of hospital infection events.
3. Further strengthen the management of the use of antibacterial drugs.
(1), according to the spirit of the Notice of the Ministry of Health on Further Strengthening the Management of Clinical Application of Antibacterials, formulate specific implementation measures and reward and punishment systems in our hospital, and pay attention to monitoring the preventive drug use during perioperative period. It is necessary to further implement the classification management system of antibacterial drugs, set prescription authority for doctors and ensure the implementation of the system. Ensure the rational use of antibacterial drugs.
(2) Strengthen the management of narcotic drugs in strict accordance with the Measures for the Administration of Narcotic Drugs, and the Pharmaceutical Affairs Management Committee will inspect the management of narcotic drugs from time to time.
(3) Strengthen the responsibilities of the Pharmaceutical Affairs Management Committee to ensure the safety of patients' clinical medication. Hospital pharmacies should conscientiously perform their duties, strictly implement the Interim Regulations on the Administration of Pharmacy in Medical Institutions, strengthen training, supervision and management, and ensure that the quality of clinical drugs and medical materials is qualified and safe to meet the requirements of clinical use. Further improve the monitoring of adverse drug reactions and report them in time. Standardize the construction of pharmacies and timely check and report drugs with short-term efficacy.
4, to meet the psychological needs of patients, close the doctor-patient relationship, reduce the occurrence of disputes between doctors and patients, and create a harmonious medical environment.
Medical staff must dress neatly, have a kind attitude and be full of energy, and introduce themselves to patients as doctors or nurses in charge, so that patients have a good impression on medical staff, a sense of trust and dependence, a sense of stability for patients, and satisfaction for their families. Only in the process of diagnosis and treatment can they actively cooperate and establish a positive and cooperative doctor-patient relationship.
Quality self-inspection report 2. The self-inspection time of engineering construction quality is from, 2005 to, 2005. The main contents of self-inspection include: general situation of the project, investment completion, plan and quantity, construction, supervision, design, basic situation of the construction unit, quality and evaluation of the project construction, evaluation opinions of the owner unit on the construction enterprise, improvement opinions and rectification measures to ensure the quality of the project construction, etc. Introduction to self-inspection (key points):
I. Overview of the Project
Main description: quality month activities and project approval, including project location, approval, scale, tasks and benefits; The general situation of engineering design changes, including the reasons, methods and results of examination and approval; Briefly explain the implementation or completion of the project.
Second, the project quality management
(1) Administration 1. Organization setting
Description: Basic information of construction, supervision, design, construction units and their on-site institutions, and on-site institutions for quality supervision and inspection.
Main description: legal representative of the construction unit, project leader, on-site quality inspection personnel; Project technical director and site design representative of the design unit; Legal representative, project manager, technical quality supervisor and on-site quality inspectors of the construction unit; The chief supervision engineer and professional supervision engineer of the supervision unit; The composition of the person in charge of project quality supervision and the members of the project station; The person in charge of inspection and technical personnel sent to the site by the quality inspection unit. (including on-the-job training and certificates, personnel changes and work conditions of key personnel of all parties involved in the construction).
(2) Regulations and standards of engineering construction management
Main description: the State Council Order
(3) Quality management system
This paper mainly expounds the formulation and implementation of a series of quality management systems and quality control measures, such as the system of joint examination of construction drawings, the system of project division and quality evaluation, the system of "joint warehouse issuing certificate" for quality inspection, the system of quality accident reporting and handling, the system of monthly supervision, the system of monthly project quality report and the system of project progress settlement.
(4) Accept quality supervision.
Main description: the division of the project and the approval of the quality supervision organization, the timely handling of quality supervision procedures and supervision acceptance, and whether there is any evaluation opinion of the supervision organization during the stage (intermediate) acceptance.
Third, the construction quality
(A) construction management
Main description: whether the construction organization arrangement, construction technology and methods are scientific and reasonable, whether the layout of civilized construction is reasonable, and whether there are any violations. , and whether the construction site test and detection work meets the requirements and requirements.
(2) Quality evaluation and project acceptance
It mainly includes: completed unit projects, sub-projects, unit projects and construction quality evaluation (qualified quantity and excellent rate, unit project appearance quality score rate, etc.). ), subentry project acceptance, stage acceptance, unit project acceptance, completion acceptance is carried out in accordance with the relevant provisions, engineering quality accidents and handling.
Fourth, the evaluation of construction enterprises
Main description: whether to strictly manage the enterprise qualification, whether to implement the management of holding certificates for key positions of the construction unit, whether to honor contracts and keep promises, whether to take the initiative to accept quality supervision and inspection by supervision and quality supervision departments, whether to standardize the management of engineering construction materials, and whether to carry out comprehensive evaluation of engineering quality evaluation and engineering acceptance in time.
Verb (abbreviation of verb) self-inspection report list
Attachment1-1:Summary of Basic Information of Water Conservancy Projects in Chongqing1-2: Inspection and Evaluation Form of Water Conservancy Project Construction Quality1-3: Evaluation Form of Water Conservancy Project Construction Enterprises in Chongqing.
Quality Self-inspection Report 3 The Project Department immediately organized relevant departments and construction teams to learn the spirit and content of the document [20xx] No.39 "Notice on Organizing 1 1 Month Quality Inspection Appraisal" issued by the construction team. According to the inspection items required by the document, our department has carried out serious inspection and investigation, as follows:
1, establishment of quality management system
Establish quality work objectives, that is, the project quality meets the specifications and standards and customer requirements; The contract performance rate reaches 100%, and the one-time acceptance rate of the project is100%; The comprehensive satisfaction rate of basic customers is over 90%, and the comprehensive satisfaction rate of customers is over 80%. A quality management system has been established, and various rules and regulations such as quality responsibility system, quality management organization and quality management system for personnel at all levels have been compiled. And the quality work in 20 13 years is decomposed into goals, and the responsibility is implemented to individuals.
2, quality inspectors equipped with and related certificates
The quality inspectors in the project department are fully equipped and can meet the project requirements. Implement the post responsibility system. The quality inspector has a strong sense of responsibility and dedication, and is responsible for the quality of each sub-project. When the sectional works are accepted, the quality control shall be carried out in strict accordance with the specifications and design requirements. Record the image data of each process of subdivisional work and the construction process of concealed works.
3, engineering entity quality, quality common fault control measures to carry out the situation
The breakwater wall adopts caisson structure with wave-absorbing holes, and the quality control in caisson prefabrication is particularly important. The common quality defects of caisson prefabrication are surface concrete honeycomb, pits and bubbles, and the roof is loose when sectioning. In view of the existing problems, in order to strengthen quality control, the project department has carried out a series of governance measures. Firstly, find out the reasons: the concrete is not dense, the quality of raw materials is poor, and the workability of on-site concrete is poor; Before form removal, the strength can't meet the standard requirements, the water-cement ratio is too large, and the workability is poor.
After finding out the reason, you can suit the remedy to the case and take the following control measures:
1) control the quality of raw materials. Generally, cement will be used for construction after three days of storage, and it is stable. Strict use of river sand, medium and coarse sand and gravel accompanied by two stages. In summer, a cooling shed is set up to control the temperature of concrete when it leaves the machine and strictly control the alkaline ion content of coarse aggregate. The saturated curing time was extended from 7 days to 14 days, and the covering curing time was extended from 14 days to 28 days.
2) Control the construction process. In the process of concrete pouring, the layered thickness shall be controlled within 40cm, vibrated with an internal vibrator, and inserted into the lower layer more than 5cm to ensure that the upper and lower layers of concrete are integrated. When pouring concrete, there must be technicians from the construction unit and the mixing station at the scene, and the mixing station should also arrange operators from the construction unit. In the process of pouring concrete, the three must communicate at any time to ensure the quality of concrete.
3) Strengthen the management and training of subcontracting teams. The cast-in-place concrete construction of this project is undertaken by the labor subcontracting team, and the prevention and control of common concrete quality defects is directly related to the quality of the management personnel of the subcontracting team. Through theoretical and operational skills training, front-line operators can master the technical points and process control points of treating common diseases, and truly realize quality improvement from an early age, quality assurance starts with me, and quality responsibility is borne by me, which has a multiplier effect on treating common engineering quality diseases.
4) Adhere to the system of monthly quality meeting to improve the quality effect of common quality defects; At the same time, the management of common quality problems is combined with refined management. Participants discussed the rectification measures and schemes, and put forward specific quality requirements for newly started projects, which were confirmed by the chief engineer of the project, implemented by the technical director and the team, and supervised by the quality controller. At the weekly dispatching meeting, all the staff of the project department will be called together, and the quality controller will analyze the highlights and deficiencies in quality management this week in the form of slides, expand the highlights and further promote them, and expand the deficiencies to warn the key points to be controlled in the next construction.
4, engineering data management
The project department attaches great importance to the management of engineering data, and is equipped with two librarians to conduct self-inspection on engineering data regularly to ensure the integrity of engineering data. Classify and file the construction materials, improve the procedures for borrowing materials, establish a document borrowing ledger and a document receiving and dispatching ledger, and strictly control the whereabouts of documents. Technical data, measurement data, test data and mechanical ship equipment data should be kept by special personnel respectively, and the data collation should be synchronized with the project and recorded comprehensively.
The course of Quality Self-inspection Report 4 is a kind of practice. As long as you study, explore, reflect and sum up your experience with your heart, you can integrate Chinese into children, turn them into smiling faces, turn them into happy learning and make them become more real development. After teaching in the first half of the year, I also got some gains from it. And found many problems from the students' mid-term exam. The summary is as follows:
First, the harvest:
1. Students "play" Chinese in middle school and experience the joy of learning Chinese.
Literacy in grade two is still one of the important tasks in Chinese learning. Literacy teaching should take language factors familiar to children as the main material. In terms of literacy, this semester, students learned to use radical search method to look up dictionaries, analyze glyphs by using ideographic features of Chinese characters, and systematically summarize and sort out word recognition methods. Students have basically learned to use different word recognition methods for independent reading. In teaching, I also pay attention to guiding students into life to read and inspiring their great enthusiasm for reading. Encourage students to memorize new words from multiple angles as a whole and advocate personalized literacy methods. Let students find the most effective literacy method, and through constant seeking for differences, activate their thinking and "play" out their value. For example, I often use the self-made children's song literacy method in teaching; Hands-on demonstration mnemonics; Distinguish the meaning of radical; Word splitting and word combination games; Through these methods, students' interest in literacy can be cultivated, so that every time they see a new word, after half a year's study, most students will remember it in various ways. In the process of literacy, it is not the back glyph, but the stage of carefully identifying each component. This not only consolidates the effect of literacy, but also improves the interest in literacy and forms the habit of diligent thinking.
2. In writing, I regard writing as an aesthetic object and a tool to cultivate noble sentiments, and always emphasize that students write words correctly, neatly, regularly and beautifully.
"Writing is an important Chinese basic skill, a means to consolidate literacy and plays an important role in improving students' cultural literacy. Be sure to lay a good foundation for writing from an early age. "Whether a person's handwriting is good or not is not only a personal' facade', but also reflects his study habits, will quality and personality characteristics to a certain extent. Therefore, in teaching, I adopted the procedure of "reading, writing with examples, commenting and trying to write": when reading, let students discuss "which stroke is the most critical to write this word", "which stroke is the most likely to make mistakes in writing this word" or "where to remind everyone to pay attention", so as to grasp the writing rules as a whole; When writing a model essay, let the students comment on the teacher's model essay, and guide the students to observe, discover and grasp the writing essentials; Let the students comment on the teacher, and use physical movements to write strokes, homework display, shining stars selection and other methods to stimulate students' interest in writing and improve their writing ability.
Second, the lack of students' knowledge and the corresponding measures to be taken in the future:
1, lack of knowledge of students:
Through the students' examination papers, the main questions focus on the following aspects:
(1), reading has always been the focus and difficulty of Chinese teaching. The reading part of several exams was not completed well. The main reasons are as follows: a. In the usual teaching, the lack of specialized independent reading training leads to the slow formation of students' independent reading ability. B, students have poor reading awareness and often read passively. C, insufficient guidance for junior students' extracurricular reading.
(2) Some questions have not been practiced, and students will make mistakes when doing them. For example, a synonym for "bright".
(3) Students' ability of analysis and judgment is poor and their imagination is not rich.
2. Improvement measures:
(1), teachers should be clear about what students have learned and achieved, and come up with solutions to problems. Train students in class, pay attention to quality for 40 minutes, and strive for the openness of ordinary students. Individual students should focus on strengthening training and strive to be clear every day. For the new questions in the book, practice repeatedly to achieve proficiency.
(2) Strengthen the training of reading ability.
Teachers should pay more attention to reading teaching in and out of class. Emphasis on mastering methods in class, expanding reading after class and consolidating reading methods. A lot of reading training should be carried out in teaching, and more attention should be paid to the focus and level of training, with goals and methods. Extra-curricular reading should also strengthen guidance, vigorously monitor students' reading process and check the reading effect. Training should adapt to students' ability and age characteristics, and improve reading ability in an all-round way. Especially for students with poor ability, we should also improve students' interest in reading and make reading easier and easier.
(3) Cultivate students' habit of accumulating and keeping diaries.
In the usual study, we should persist in the accumulation of students and the cultivation of diary habits, strengthen more effective guidance and improve students' practical application ability.
(4) Strengthen the guidance of learning methods.
In the usual study, let students carefully examine the questions, guide students how to answer them, and make clear what the main points are, especially when reading. .
(5) Strengthen post-examination inspection training.
In the usual study, students are required to carefully check the test papers, correct mistakes in time when they find them, and persist in training for a long time, so that students can develop the good habit of checking.
(6) Continue to strengthen the cultivation of good writing habits. Judging from this exam, students' writing ability has been greatly improved, but there is still a big gap compared with the requirements of teachers. Developing good habits is not a one-off event, so we must stick to it. Students are required to standardize their writing, not only by writing texts and copying new words, but also by "practicing writing while writing". Only by putting this requirement in place can we really develop good writing habits.
The above is my harvest in the past two months, but there are still many shortcomings. I will continue to work hard and explore to find a more suitable teaching method for my students.
Quality self-inspection report 5 I. Medical quality management
Our hospital pays close attention to service quality, prevents medical errors, practices according to law and practices in a civilized way. The hospital has set up a leading group for medical quality management headed by Vice President Zhang, which regularly checks prescriptions and medical records, timely feeds back relevant responsible persons and supervises the medical quality of the hospital. The quality control of each single disease has reached the standards of the city and district.
Second, medical documents
Strictly abide by the requirements in the Basic Specification for Medical Record Writing, and write all medical documents objectively, truly, accurately, timely and completely for patients.
Third, rules and regulations
Our hospital has improved and implemented a series of rules and regulations, and improved various management systems, including thirteen core systems, new technology access system, pharmaceutical affairs management system, and public emergencies management system. For patients who see a doctor on the spot, they are required to show their medical certificates and ID cards when registering, and the hospitalized patients are required to submit copies of the two certificates during hospitalization, and carefully check them to prevent impersonation. Strictly grasp the admission criteria, follow the outpatient treatment, resolutely not be hospitalized, be admitted to the hospital in strict accordance with the criteria, do not arbitrarily reduce the hospitalization index, and do not delay the hospitalization day.
Our hospital strictly abides by the relevant medical insurance system, organizes the medical staff of the whole hospital to study the relevant medical insurance policies repeatedly, and carries out assessment work. The assessment results are linked to the distribution of personal interests.
Fourth, the basic drug system.
For the examination and treatment of inpatients, our hospital strictly follows the provisions of the Catalogue of Essential Drugs. Every doctor is required to strictly abide by the professional ethics and do it seriously.
Reasonable inspection, rational drug use, reasonable treatment and reasonable charges can effectively reduce the burden of medical expenses for farmers by using low-priced drugs instead of high-priced drugs. The inventory of drugs in the drug storehouse has reached more than 90% as stipulated in the catalogue. The dosage of prescription drugs is strictly controlled. In-patients should use drugs for no more than 3 days, and discharged patients should use drugs for no more than 7 days. It is strictly prohibited to prescribe drugs, show human feelings and abuse drugs, and the number of days of taking drugs out of the hospital shall not exceed the actual number of days of hospitalization. Check in strict accordance with the regulations, and resolutely put an end to the phenomenon of one-person medical insurance for the whole family.
Verb (abbreviation of verb) medical expense control
Our hospital charges in strict accordance with the charging standards jointly formulated by the departments of price, health and finance of provinces, cities and districts. Pay close attention to connotation construction, improve service quality, shorten the average hospitalization days of patients, and strictly control hospitalization expenses.
Sixth, medical assistance.
This year, the municipal and district health bureaus have stepped up medical assistance, and experts and professors from the Municipal Infectious Disease Hospital and the First District Hospital have gone to the countryside for medical assistance, which is of great help to improve the professional knowledge level, improve the knowledge structure and update the latest professional trends of frontline medical staff.
VII. Current shortcomings
1. Due to insufficient funds, some medical equipment cannot be repaired or updated in time, which affects the in-depth development of related businesses to a certain extent, and the professional development is insufficient.
2. High school doctors can't master the computer well, and they can't realize all electronic prescriptions, which has certain resistance to improving outpatient co-ordination.
3. It is found that some doctors have unqualified prescriptions, including unqualified prescription formats, and the proportion of antibacterial drugs used in outpatient clinics is greater than 20%.
VIII. Direction of future efforts
Our hospital must take this hospital grade review and annual assessment as an opportunity, under the leadership of the superior business department, strictly abide by the management regulations of medical institutions, strengthen management measures, optimize the quality of personnel, be pragmatic, blaze new trails, and constantly improve the quality of medical services and technical services.
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