Hospital medical safety self-study report
In our ordinary daily life, more and more matters will be used in the report, the report has a two-way communicative nature. Then you really know how to write a good report? The following is my compilation of hospital medical safety self-examination report, welcome to read and collect.
Hospital medical safety self-inspection report 1
In the hospital's leadership attention, for the current bad medical behavior of certain medical units, the hospital carried out a comprehensive self-inspection and self-correction of the work of the inspection. Laboratory Section of the management of the section, quality, safety, service and other aspects of a comprehensive self-examination and self-correction checks. After three days of self-examination and self-correction, against the relevant medical rules and regulations, found a number of hidden dangers, the development of relevant measures. Briefly summarized as follows:
1, the quality of specimens most of the specimens qualified, unqualified specimens have a record of rejection and re-sampling treatment. Problems: insufficient communication with the Department of Nursing and nursing care in the districts, to more comprehensive and timely reflection of the quality problems in blood sampling. Measures: Quarterly will be related to the quality of specimens in the form of a table to reflect to the nursing department, in order to promote the improvement of the quality of pre-test.
2, indoor quality control all carry out the project can adhere to the daily indoor quality control, there are records, the point of loss of control has been analyzed, there is treatment. Quality control is good.
3, inter-room quality control can participate in the annual Foshan City, Guangdong Province, the Ministry of Health of various types of projects inter-room quality. There are records and feedback analysis, strict control of the person in charge of quality. The same type of analytical instruments have measured the value of regular comparison, the data show that the results between different analytical instruments in a reasonable acceptable range.
4, the critical value reporting system of each laboratory can be seriously implemented, there are records and processing. Problems, found 1 case of false critical value improper handling. Measures: Strengthen the staff's business ability to learn and training, and constantly improve their own professional ability. The handling and reporting of critical values are standardized and implemented. The company's website has been updated with the latest information on the latest news.
5, on dangerous goods, safe use of electricity, fire hazards inventory. Hazardous materials are managed under lock and key, and there is a registration of use. Not found electricity, electrical use of safety hazards. No potential fire hazards were found
Diseases. Fire fighting equipment is qualified and stored according to requirements.
6, the service ability to send reports on time, the timely rate of inspection reports reached 95%. Service satisfaction of 90%. Rating for the time 84 points. Service level and quality still need to be continuously improved. Strengthen the ideology and professional ethics education, establish a new style of the industry, create a civilized service window.
The self-examination and self-correction inspection, to improve the quality of my test has a great role in promoting, to protect medical safety, to eliminate medical hazards has a positive significance.
The hospital medical safety self-check report 2
According to the spirit of the relevant documents and regulations of the higher level, our hospital immediately conducted a medical quality inspection and made the following summary:
First, pay close attention to the quality of medical care, to ensure medical safety
1, strictly in accordance with the process and diagnosis and treatment guide to carry out clinical work, to ensure the quality of medical care and medical safety.
2, the strict implementation of the doctor's room system, and need to be in the condition of the record on the detailed records of the room: the analysis of the condition, medical treatment and the next step in the diagnosis and treatment plan records.
3, the strict implementation of the management system of practicing physicians.
4, the strict implementation of the physician duty system,
5, do a good job in the evening checkup. Evening checkups include the newly admitted patients, critically ill patients, the results of medical treatment during the day to follow up, the results of the analysis and processing of test results, special test results, informed consent communication (especially for patients who will undergo surgery or invasive tests), the patients who will be discharged tomorrow, the treatment of patients in the consultation, and so on. And with the physician on duty to carry out the work of shift handover.
6, do a good job of shift handover. The morning shift and the afternoon shift before the end of the shift is particularly important, critical patients must be bedside shift. The physician on duty every day after the shift must be the patient's undergraduate test single detailed access to once, and abnormal results for processing and review.
7, the implementation of the implementation of the consultation system.
8, the department set up a special quality control inspection of medical records responsible for physicians, random sampling of medical records and do a good job of quality control, timely revision of errors and omissions.
9, for the checkup of the various feedback information, and put forward the views of the problems found in a timely manner to do a good job of rectification, to avoid making the same mistakes.
10, led by the director of the department every month, business learning, update the new knowledge and new progress in diagnosis and treatment.
11, the section of the irregular, no advance notice of the quality inspection, found that the problem, the deadline for rectification, to help implement
12, the establishment of difficult cases consultation and discussion system, the purpose is to solve the difficult cases of diagnosis and treatment at the same time, improve the overall academic level of the various disciplines and at the same time, the training of physicians and to improve their clinical competence and level of business.
Second, the implementation of the system, strengthen the communication between doctors and patients to enhance the understanding of doctors and patients
1, communication is a very important link.
(1) to do a good job of communication at the time of admission: let the patient and his family to understand the patient's current condition, critical patients to the physician to explain the condition in detail, if necessary, sign the sick (critical) serious notice. To let the patient and his family to understand the name of the physician and nurse, and know the time of the communication of the condition.
(2) hospitalized communication: changes in the condition, test results, treatment programs; especially diagnosis and treatment of major changes, more timely communication. For patients who can not come to the hospital in time to understand the condition during the day, the condition must be handed over to the physician on duty, so that the patient's family with the physician on duty to understand the condition.
(3) communication before discharge: the diagnosis of the disease and the results of treatment, outpatient follow-up time and the possible side effects of drugs, the condition of the possible changes in the treatment method, the need to review the examination program.
(4) outpatient communication: diagnosis and treatment of the disease, the role of drugs and side effects, follow-up time.
(5) communication between doctors and nurses: the implementation of medical behavior in place in a timely manner, whether a variety of timely examination, whether changes in the patient's condition has been dealt with in a timely manner, whether there are hidden medical problems or disputes.
2, seriously implement the signing of informed consent. For the relevant treatment, must be treated by the personnel and family and the patient for face-to-face communication, the necessity of the diagnosis and examination, indications, possible risks and complications, medical costs, medical needs to be observed or treatment time to the patient's family to explain, and sign the informed consent.
3, 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 members, the establishment of a full-time chaperone, and do a good job of handover work.
4, reasonable deployment of the department of extra beds, in order to improve the quality of medical care and ensure medical safety under the premise of the sustainable development of the department must have a clear goal and direction.
Hospital medical safety self-inspection report 3XXX Limited was established in October 20xx, is a small pharmaceutical wholesale enterprises. The business site is located in X, the registered capital of 3.1 million yuan, is a set of pharmaceutical wholesale, distribution, operation as one of the pharmaceutical logistics enterprises. Mainly engaged in the wholesale and distribution of proprietary Chinese medicines, chemical preparations, antibiotics, biochemical drugs, biological products, Chinese medicine tablets, health care products and two or three types of medical devices and other wholesale business. The company operates medical equipment with an office, medical equipment quality control section, medical equipment sales section, medical equipment storage and transportation section, engaged in quality management personnel 4: 1 quality administrator, 1 internal auditor, 1 acceptance inspector, 1 caretaker, medical equipment special library area of 210 square meters.
The company obtained the "Medical Device Business License" in January 20xx, and strictly implements the "Regulations for the Supervision and Administration of Medical Devices" and "Medical Device Business Management System" in the management of medical devices. We carry out all-round and whole-process quality control of the medical device products we operate to ensure the safety of consumers. A few days ago, for the license renewal work, our company in accordance with the requirements of active preparation, and conduct a rigorous self-examination. First of all, the self-inspection report is as follows:
(a) institutions and personnel:
1, the company has a reasonable organizational structure (see the attached table "XX Co., Ltd. organizational setup and function of the block diagram").
2, XX Co., Ltd. and the person in charge of the enterprise XXX, familiar with the national supervision and management of medical devices regulations, rules and regulations and have the appropriate professional knowledge.
3, the company has a quality management section, is responsible for the product procurement audit, warehousing quality acceptance, storage and maintenance management processes such as monitoring; the operation of medical devices on time or from time to time to collect the quality standards and the country's relevant technical standards, and to guide the company's business purchases and quality acceptance; on the development of the company's "Medical Device Management System" implementation of the inspection and assessment. This ensures that the company's business quality and safety to implement effective monitoring.
(B) business premises and storage facilities
1, the company has a relatively independent and centralized business premises with property rights in line with the scale and scope of business. Business area of 300 square meters, clean, bright, hygienic environment, and equipped with desks and chairs, telephones, file cabinets, computers and other office equipment.
2, the company's medical equipment library is relatively independent and business scale and scope of operations to adapt to the warehouse area of 210 square meters.
3, the warehouse is clean and hygienic, the walls, roof and floor are flat, dry, no shedding, doors and windows are tightly structured and set up the necessary mats and shelves; set up in line with the safety requirements of the lighting facilities; fire fighting and ventilation facilities; there are facilities to avoid light, dust, insects, rodents, moisture, pollution and so on; set up to cool, refrigerated equipment and temperature and humidity monitor and temperature and humidity control equipment. The company's warehouse is divided into "five zones" and the implementation of color-coded management: pending inspection area (yellow), qualified products area (green), non-qualified products area (red), shipping area (green), return area (yellow). In addition, there is also a period of product visibility signs.
4, the environment around the warehouse is clean, dry, no stagnant water, no dust, no pollution and isolation of office and living areas.
(C) system and management
1, the company developed in line with its own actual management system and strictly enforced, quality management system, including business organizations and relevant personnel 's management functions; the first business, the first varieties of audit system; expiration date product management system; product after-sales service system; product procurement, acceptance, storage (maintenance), out of the review and sales management system; Unqualified products management system; returned products management system; quality tracking management system; adverse event reporting system; quality information collection management system; quality incident reporting system; measuring instruments management system; quality problems query complaints management system; education and training management system; installation and maintenance management system; after-sales service management system; hygiene and health status management system; user access contact management system; Computer management system, etc.
2, the company's quality section has collected and preserved the operation of medical devices related to laws and regulations, as well as the use of products related to standards or related technical materials.
3, the company has established a true and comprehensive quality management records to ensure product traceability. Quality management records include: medical device first enterprise, the first varieties of audit records, product purchase, acceptance, storage and maintenance, out of the warehouse review and sales records; temperature and humidity records; in and out of the warehouse documents; unqualified products, returned products, quality information, adverse events, quality accidents, inquiries and complaints of the report and processing records; expiration date management, after-sales service and other links of quality tracking management, always ensure that product traceability. Traceability.
(D) Purchase and acceptance
The company purchases medical devices in strict accordance with the provisions and procedures of the medical device purchase system. The supply unit, the legitimacy of the purchased products are strictly audited, and the quality assurance agreement is signed with the supplier every year, and the quality terms are clearly defined. Purchase of drugs have legitimate bills, and the establishment of purchase records, tickets, accounts, goods in line.
For the purchase of medical devices, the acceptance of personnel familiar with the quality of the products operated by the company's performance, and according to the relevant standards, original documents and quality verification methods batch by batch acceptance, but also on the medical device manuals, labels and bags labeling, as well as the relevant supporting documents, certificates of conformity and random documents to check, acceptance of the qualified only after storage and sales, the quality of the abnormalities, labeling ambiguity of the medical device Be rejected. Medical device quality acceptance should have acceptance records. Acceptance inspection records document the date of arrival, supply unit, product name, specifications, quantity, registration number, production batch number, manufacturer, quality status, acceptance conclusions, etc. Acceptance inspection records should be kept until 2 years after the expiration date of the product. In addition, the sale of returned products, acceptance of personnel in accordance with the provisions of the incoming acceptance, and indicate the reason for the return.
(E) storage and custody
1, medical devices according to the specified storage conditions and requirements for classification and storage, storage to do: expiration date products stored in the area, disposable sterile class and other medical devices are stored separately, medical devices and non-medical devices are stored separately; medical devices and the warehouse floor, wall, top to leave the appropriate distance between the isolation measures; medical devices according to the classification of the product Relatively centralized storage; temperature and humidity storage requirements of medical devices according to its temperature and humidity requirements for storage and the corresponding storage area or equipment.
2, the library of products placed in a clear state identification, state identification of the implementation of color-coded management, divided into green, yellow, red three colors: green for qualified products; non-qualified products for the red; to be tested or returned to the sale of yellow.
3, storage and custody of quality problems found, hanging obvious signs and suspend shipments, and as soon as possible to notify the Quality Section to be confirmed, and according to the confirmation of the views of the treatment.
(F) out of the warehouse and transportation
1, the product out of the warehouse, the custodian in accordance with the bill of sale or distribution vouchers on the physical
quality inspection, number, project verification, correct before shipping out of the warehouse. If quality problems are found, the shipment should be stopped and reported to the quality department.
2, the transportation of medical equipment, packaging for the delivery of products, road conditions and means of transportation, to take appropriate protective measures to prevent the product quality problems in the transportation process. In the transportation of products with temperature requirements, to take appropriate thermal insulation or refrigeration measures.
(VII) sales and after-sales service
1, the company in accordance with relevant laws and regulations, medical devices should be sold to units with legal qualifications. It does not deal with unregistered, unqualified, expired, invalid or obsolete products.
2, the sale of medical devices to issue legal bills, and according to the provisions of the establishment of sales records, to achieve the ticket, account, goods in line. Sales records include: date of sale, customer name, product name, sales volume, production units, model specifications, production batch number, invoicing salesman and other content. Sales records should be kept until the product expiration date after 2 years.
3, for special reasons need to be transferred directly from the supplier to the user's medical equipment, the company needs to confirm the quality of the product, and make the relevant records.
4, the company regularly collects quality information, timely reporting, processing and feedback. If quality problems are found in the sold products, they should be recalled in time. And reported to the drug and equipment regulatory authorities, and make relevant records.
5, the company in accordance with the provisions of the national medical device adverse reaction reporting system and the company's relevant systems, timely collection of medical devices sold by the company's adverse events. If you find that the products operating adverse events, in accordance with the provisions of the timely report to the relevant departments.
6, the quality of inquiries, complaints and sales process of quality problems to identify the causes, to distinguish between the responsibilities, to take effective measures to deal with, and make a good record.
Hospital medical safety self-examination report 4In order to strengthen the management of medical safety, to prevent the occurrence of various types of accidents, and effectively establish a "patient-centered" concept of medical services, to create a "safe hospital", and carry out the "three good and one satisfaction" in-depth. "Three Good and One Satisfaction", "Medical Quality Miles", "Antibacterial Drugs Clinical Application Special Remediation" program requirements, our hospital has carried out medical quality and safety self-examination and self-correction activities. Now the self-inspection report is as follows:
First, standardize the practice of medicine, standardize the practice of medicine, strengthen the management.
Strict implementation of the relevant laws and regulations, the strict implementation of the access system of medical institutions and medical personnel access system, our hospital's medical institutions license is in effect, the hospital in accordance with the "medical institutions license" scope of practice to carry out diagnostic and therapeutic activities, no unauthorized expansion of the diagnostic and therapeutic subjects, without the employment of unlicensed personnel, no violations of the phenomenon of the release of medical ads, and so on. We have organized the study of health laws and regulations, rules and regulations, and routine norms. We have carried out the "Medical Practitioners Law", "Nurses Regulations", "Infectious Diseases Prevention and Control Law" and other health laws and regulations, through the development of special lectures and study groups to focus on learning, medical staff self-study and other forms of learning, so that medical staff to understand the mastery of the health laws and regulations, rules and regulations, routines and norms, to strengthen their awareness of the law and self-protection awareness, and to enhance the conscientiousness of the law practice.
The second, pay close attention to the quality of medical care, to ensure medical safety.
Strengthened the work of production safety, the strict implementation of the core system of medical care, strict compliance with the "Jiangxi Province, the basic drug system", to strengthen the management of the rational use of antibacterial drugs clinical; strengthened the management of hospital infections; to strengthen the work of first aid, strong first-aid technology, strengthen the first aid of the medical staff of the basic skills training, to improve the emergency treatment capacity and level; and to
further standardize the hospital clinical transfusion. p> Further standardized the hospital clinical blood transfusion management. Each department strictly in accordance with the diagnosis and treatment process of specialized diseases, to carry out clinical work, to ensure medical quality and medical safety. Strict implementation of the third-level doctor check-up system, and the need for detailed records of check-ups on the record of the condition, the analysis of the condition, medical treatment and the next step in the diagnosis and treatment plan records. Strictly implement the management system of practicing physicians; strictly implement the system of doctors on duty, do a good job of shift handover, and critical patients must do bedside shift handover. Implement the implementation of the consultation system. Each department quality control physician to strengthen the allegations, improve the quality of the case.
Three, the implementation of the system, strengthen the doctor-patient communication to enhance the understanding of doctors and patients.
Seriously implement the signing of informed consent, communication at the time of admission, communication at the time of hospitalization, communication before discharge, communication of outpatients, communication between doctors and nurses, the implementation of medical behavior in place in a timely manner, a variety of timely examination, whether changes in the patient's condition is dealt with in a timely manner, there is a medical hidden danger or dispute.
Four, the establishment of a medical safety incident reporting system and emergency response plan, in order to further strengthen the monitoring and management of the deepening of the idea, awareness. Combined with the actual unit, the establishment and improvement of the corresponding management organization and system, the implementation of the staff equipped with full-time (part-time) staff, and assume responsibility for the management of the work, to strengthen the leadership, to implement. After the medical safety self-examination, our hospital can strictly abide by the laws and regulations of the country, practicing medicine in accordance with the law, standardized practice, practice activities in line with the standards of practice verification, to further improve the level of medical services and management standards, improve the service awareness, optimize the service process, improve the service attitude, enhance the service skills. According to the existing problems and corrective measures to seriously improve all aspects of medical and health care, comprehensively promote and enhance the health of medical services, and strictly prevent the occurrence of medical safety incidents, to provide the public with a safe and secure medical environment. However, due to a variety of subjective and objective conditions of the limitations of our work, there are certainly many shortcomings, here I implore the superiors to give more guidance and support, so that we in the future work, continuous improvement, better service for the people in the area.
Hospital medical safety self-inspection report 5In order to further strengthen hospital management, improve the quality of medical care, to protect the people's medical safety, in accordance with the requirements of the Municipal Bureau, the morning of xx, xx, 20xx, our hospital medical department organized the relevant personnel of the hospital and the jurisdiction of the health institutions to carry out unannounced inspections of the medical safety hazards, is now the report of the inspection situation is as follows:
I, Problems
1, medical instruments written lack of standardization, individual village health center there is not timely record phenomenon.
2, village health centers generally disinfection infection record no or irregular phenomenon.
3, the village health center medical waste classification is not standardized.
4, the village health center of medical quality and safety management system is not sound, the disposal process is not clear, the operation is not strong.
5, the village health center infusion rate is generally high.
6, the village health centers are not equipped with qualified firefighting equipment according to regulations.
7, Guangming, Zhongcun, Jiangshan village health center indoor circuit aging, there are serious safety hazards.
8, bright village health center housing structure aging, wood structure material more, there are safety hazards.
9, part of the oral medication is not timely written medical records, less communication with the patient, medical history collection is incomplete, the patient informed not in place.
10, the central health center health insurance card without verifying the patient's identity, resulting in gynecological drugs used by men, men's drugs used by women.
Second, corrective measures
1, to strengthen the knowledge of medical and technical personnel to standardize the writing of medical documents training, quarterly arrangements for the relevant personnel to carry out inspections, so that the medical documents written in a timely manner, standardized, accurate and error-free.
2, the village health office personnel to strengthen the knowledge of hospital infection training, quarterly organization of relevant personnel to standardize the census.
3, the village health room personnel focused on the standardization of medical waste classification and disposal of learning, and quarterly inspection.
4, to strengthen the village health office personnel safety medical knowledge training, the village health office of medical quality and safety systems, processes to make standardized guidance.
5, to strengthen the village health room three rates of regular and occasional inspections, urged to standardize the use of drugs.
6, the organization of village health office personnel to carry out production safety training and fire safety regulations to improve the awareness of production safety, and urge the existence of hidden safety hazards for active rectification.
7, to strengthen communication with patients, medical history collection is complete, necessary to do a good job with the patient or family informed of the work.
8, the health insurance card to do a good job of identity verification, be sure to every party must be right, every party must check.
9, ordered the security conditions of the village health center is not enough to carry out the necessary environmental transformation to adapt to the requirements of production safety.