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Nursing quality management standard
0 1 Implement International Patient Safety Objectives (IPSG)

JCI pays special attention to the following seven aspects, including 7 standards and 24 measurement elements. IPSG is the core standard that must be met and belongs to the one-vote veto system.

1). Correctly identify patients: We have formulated standardized documents, which clearly define two bases for identification (name+date of birth) and the use range of wristbands. It is emphasized that whether it is infusion, drug administration, treatment or other operations, the patient's identity confirmation should not only ask the patient's name correctly, but also check the date of birth with the patient or his family. It is also required to ensure that all medical documents must include the patient's name and date of birth.

2) Improve the effectiveness of communication and put an end to adverse events caused by poor communication. Our hospital has made it clear that oral medical orders can only be used to rescue patients. The items and ranges of critical values issued by medical technical inspection departments such as examination, ultrasound, electrocardiogram and endoscopy room, such as adult blood sugar < 2.5 and > 22.2, must be notified to clinicians within 10 minutes. Nurses are required to strictly follow the procedure of recording-retelling-confirming-reporting when carrying out oral medical orders and receiving critical value reports. The doctor should take measures within 30 minutes after receiving the critical value report and record it in the medical record. Establish patient rescue records, critical value registers, important telephone communication books, etc.

3) In order to ensure that the patient is correct and the surgical site is correct, it is required to execute the "pause" procedure before the operation or other operations officially begin. We designed a record sheet for the handover of surgical patients, and recorded the patients' preoperative preparation, surgical site identification, arrival time in the operating room, intraoperative situation and postoperative resuscitation room through a form. In order to make the operation standard consistent, we took out the teaching video of the operation time, and stipulated which marker to use for the pictures of different operation parts.

4). High-risk drug management: unified identification in the whole hospital, with high-risk drugs and special warning signs for drugs that are similar in shape and well-deserved; All units have defined the list of high-risk drugs. Except for the operating room, all other units are not allowed to store potassium chloride, which is centralized by the static distribution center. The temperature and humidity requirements of the drug storage environment are specified, and the safety of the storage environment is routinely monitored every day. It is required that drugs must be handed over every day, and the list of drugs with high concentration electrolyte, insulin and chemotherapy drugs must be checked and signed by two people. Has been released. Usage records must be consistent with the doctor's advice and prescription, and at the same time with the pharmacy outbound records.

5) Strictly implement the hospital infection prevention and control system to reduce the risk of medical-related infection. Emphasize the importance of hand hygiene, hang a hand washing flow chart on each sink, and equip it with hand sanitizer and paper towels. In the elevator room, at the door of the ward, treatment car, nursing car, oral medicine car, etc. , equipped with quick hand disinfectant, play hand washing video to improve the hand washing rate of staff, patients and their families.

6). Prevent inpatients from falling (falling out of bed), assess the risk of falling for all patients, including outpatients, design special evaluation and re-evaluation sheets, find high-risk groups in time and take intervention measures to prevent falling out of bed and falling. It is stipulated that patients who fall should wear wristbands with special colors, and anti-fall signs should be hung at the door and bedside of the ward. Special fall prevention education sheets should be designed and distributed to high-risk patients and their families to reduce the occurrence of patients falling out of bed and falling. For children patients, we use special beds to reduce the occurrence of children falling from the bed.

7). Establish a quality monitoring plan, implement patient safety objectives, and make continuous improvement: for each safety objective, formulate a quality monitoring plan, such as the correct implementation rate of patient identification before intravenous infusion, the implementation rate of hand hygiene, the incidence of falls of hospitalized patients, the timely reporting rate of critical values, and the correct implementation rate of overtime. , each indicator has a target value. The person in charge collects and analyzes the data every month, analyzes the reasons and submits the continuous quality analysis report.

To carry out systematic nursing evaluation and provide basis for implementing personalized nursing plan.

Patient evaluation (AOP) is also an important chapter of JCI standard, and it is also one of our difficulties. While dealing with a large number of treatment tasks, it is required to evaluate patients timely and correctly and make nursing plans. Undoubtedly increased the workload of clinical nursing staff. Our hospital has formulated a nursing evaluation system and designed an admission nursing evaluation form as a preliminary evaluation of newly admitted patients. Then, according to the problems existing in the initial evaluation, a special evaluation record sheet in the form of pain, fall, pressure sore, constraint, special population and dying patients is designed, which is convenient for nurses to fully understand the patient's condition, find problems in time and formulate feasible personalized nursing plans. In order to popularize the evaluation system, through organizing training, on-site guidance, template table making and quality monitoring plan, the "timeliness of pain screening for inpatients" is taken as the monitoring plan, and continuous improvement is made.

Protect the rights of patients and their families

It is difficult to cover all the chapters that are the easiest to deduct points. We were deducted because the interval sound effect of stomatology clinic was not good and the privacy of patients was not protected. Mainly emphasize knocking at the door before entering the ward; The ward is equipped with a plastic box with a lock for recycling waste paper with patient information; Empty bottles recovered after infusion should be stamped with the patient's name; When the patient goes out for examination, the medical record should be packed in the medical record delivery bag; The ward has a special doctor-patient communication room; There is a sign "Don't talk about illness" in the elevator room; In order to protect the patient's privacy, we need a room with one person and the back closed. For emergency infusion room, operating room and other places where privacy protection is difficult, post tips to inform patients that they can make requests if they have special needs. In order to ensure the rights of patients and their families, we signed a general informed consent form when we were admitted to the hospital to inform the hospital of the norms and needs of diagnosis and treatment, and at the same time issued a leaflet on patients' rights and obligations.

Patient health education reflects the whole process.

JCI pays attention to the hospital to provide effective health guidance for patients and promote their rehabilitation and follow-up treatment. We design health education files for different specialties, such as internal medicine, surgery, pediatrics and obstetrics. On the basis of evaluating the learning needs of patients and their families, we first make a health education plan according to the needs of patients' illness, record the implementation time and effect evaluation. According to the common diseases of different specialties, colorful health education leaflets were made and placed in every corner of the hospital. For the production and update of health education leaflets, we will arrange, number and review them by the hospital health education team to ensure the standardization and scientificity of the leaflets.

Strictly evaluate, train and assess the qualifications and abilities of nurses.

JCI attaches importance to the qualifications of nurses and the education and training given by hospitals to ensure that nurses have the ability to serve patients. Medical staff in the whole hospital must hold the certificate of cardiopulmonary resuscitation, and nurses in special positions such as emergency room, intensive care unit, resuscitation room and operating room must hold the ACLS training certificate, which is valid for two years. For new nurses, they must receive necessary knowledge training in fire fighting, hand hygiene, cardiopulmonary resuscitation and international safety objectives. , and can only be employed after passing the examination. Before working independently, they must receive corresponding specialized training and pass the examination before they can work at their posts; Every nursing staff must sign a job description, and the hospital and nursing department should conduct professional training and assessment according to the requirements of the job description. The hospital should confirm the authenticity of each nurse's academic qualifications, professional titles, practice certificates and other qualifications.

Establish a culture of continuous quality improvement

JCI believes that the task of quality management is not only to find problems and eliminate hidden dangers such as employee mistakes, but more importantly, to establish a safer system through continuous quality improvement. We learn and establish a culture of continuous improvement of nursing quality through JCI certification. Each nursing unit monitors quality indicators, takes the lead in carrying out PDCA improvement and quality control circle activities in hospitals, and participates in the project of failure mode analysis of chemotherapy drugs in hospitals. Implement a non-punitive abnormal event reporting system and actively report nursing adverse events; Create a clean medical environment in each ward through 5S management; Intensive care unit (ICU) implements cluster management of VAP standard preventive measures for patients treated with ventilator, which effectively reduces the occurrence of VAP.