Self-inspection report on medical safety in clinical laboratory
According to the requirements of medical quality and safety rectification activities in medical institutions, our hospital conducted a comprehensive inspection of key departments. The self-examination results, rectification opinions, measures and specific rectification responsibilities are reported as follows: 1. Review of the basic situation of medical quality and safety management in our hospital:
(1) Our hospital has a sound safety management system, with clear responsibilities and responsibility to people. Formulated the medical quality and safety management scheme and assessment standards, and improved the responsibilities of various medical management systems. In accordance with the requirements of the management plan and assessment standards, medical quality management regularly goes deep into the supervision and inspection of departments to urge the implementation of the core system. The examination results are linked to the hospital performance appraisal scheme in the form of quality scores, which effectively promotes the continuous improvement of medical quality and medical safety management.
(2) Strengthen the education of medical quality and medical safety, and the safety awareness of medical staff is constantly improved.
We conduct quality and safety education for all employees in the form of safety meetings, and sign safety responsibility letters with relevant personnel of various departments. The training and assessment of laws, regulations and rules and regulations have been strengthened. Hold "medical quality and safety" training. After the safety inspection, the quality control department of the hospital held a meeting to carefully study and analyze the problems and disputes found in the inspection, find out the core problems and rectification measures, and then held a meeting of section chief, head nurse and business backbone to evaluate the quality, which effectively promoted the improvement of medical quality.
Strengthen the training and assessment of "three basics" and "three strictness". According to the "three basics" training assessment plan at the beginning of the year, all departments must be assessed once every quarter, and the medical department and nursing department must hold the "three basics" assessment of the whole hospital every six months. The reference rate and qualified rate must be above 95%.
(3) Improve the plan for preventing medical disputes and accidental injuries caused by non-medical factors, and establish a mechanism for preventing and handling medical disputes.
(4) Nursing management
(1) nursing management organization
Be able to implement nursing management in strict accordance with the provisions of the Nurses' Regulations, organize head nurses and nursing staff to seriously study the Nurses' Regulations, and be knowledgeable, law-abiding and practicing according to law.
(2) Nursing human resource management
Make on-the-job training plan for nurses every year, including three basic studies, business lectures, nursing rounds, etc. Seriously carry out the plan.
(3) Clinical nursing management
Establish the concept of humanized service to ensure that patients' informed consent is implemented. The perioperative patients were visited before and after operation, and a standardized scheme was designed. All departments attach great importance to health education and have formulated the contents of health education.
(5) Hospital infection management
(1) Establish and improve the hospital infection management organization.
(2) The responsibilities of the hospital infection control management organization have been implemented.
According to the actual situation and task requirements, our hospital formulates the hospital infection management work plan every year, so as to organize the implementation and assign responsibility to people. Hold a hospital infection management meeting once a year to summarize the recent hospital infection management work, solve the common problems found in daily work, and arrange the work focus for the next period.
(3) Strengthen the training of hospital infection management knowledge, and constantly improve the medical staff's awareness of hospital infection control and disinfection and isolation.
(4) Seriously carry out hospital infection control and disinfection and isolation monitoring, which reduced the hospital infection rate and never caused an outbreak of hospital infection. Strengthened the management of disposable articles. All departments strictly implement the Management Measures for Disposable Sterile Medical Supplies, and disposable medical and health supplies are uniformly purchased, stored and distributed by the Equipment Department, and the "three certificates" are complete. All departments should collect it according to their needs, so that it can be used before it is used and used within the validity period. Disposable articles shall be collected by special personnel after use, and it is forbidden to reuse and return to the market.
Second, the existing problems:
(A) part of the medical management system has not been fully implemented.
The quality and safety awareness of individual medical staff is not high enough, and the core systems such as the responsibility system for first-visit doctors and case discussion system are sometimes not well implemented, so case discussion still needs to be handled. The evaluation system of patients' condition is not perfect, and the risk assessment of surgical patients is limited to preoperative discussion or summary, and no written risk assessment system has been established.
(2) The application of antibacterial drugs is still unreasonable.
The use of antibiotics by individual medical staff is unreasonable, and antibiotics are also used for common colds; Prophylactic medication in perioperative period is unreasonable, the application level of antibiotics is too high and the time is too long.
(3) There are still many problems in writing hospital medical records.
1, lack of analysis of the modified doctor's orders and positive test results in the course records, less analysis of the contents of rounds, and some like to keep accounts.
2. The informed consent form was not signed, and the informed consent form was not signed for self-funded medication.
Third, the rectification measures:
(a) to further strengthen the quality and safety education, improve the safety and quality awareness of medical staff.
Medical staff generally attach importance to professional knowledge and ignore the study of quality management knowledge, lack quality management knowledge and have a weak sense of quality, so that they can not consciously and actively apply quality requirements to daily medical work, and it is difficult to ensure the realization of quality objectives. Quality management is a discipline. To improve medical quality, we should not only learn medical theory and technology, but also learn the basic knowledge of quality management and constantly update the concept of quality management to meet the needs of society. Only by making medical staff establish correct quality management consciousness and master quality management methods can passive quality control be changed into active self-quality control. Therefore, it is one of the basic tasks to improve medical quality by training all medical staff on quality management knowledge and enhancing quality awareness. First of all, it is necessary to strengthen the training of medical-related laws, regulations, rules and regulations and the responsibilities of personnel at all levels. Our hospital has vigorously carried out system construction and compiled various laws, regulations, systems and responsibilities of personnel at all levels. It is necessary to seriously organize and study the Job Responsibilities of Hospital Staff, Selected Common Laws and Regulations of Hospitals, and Medical Quality and Safety Management Manual. Medical staff must master relevant laws and regulations, core systems and personnel responsibilities, and organize an assessment of medical skills, rules and regulations and responsibilities of all staff in March, and record the results in personal files. Strengthen the study of basic knowledge of quality management of medical staff, and improve their awareness of quality, safety and prevention.
(2) Strengthen supervision and inspection to ensure the implementation of the core system.
1, the medical department should further strengthen the quality ward round and medical record examination, which is a good measure to improve the quality of medical care, 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.
2, strengthen the three basic training and assessment, to constantly improve the assessment methods, serious assessment discipline, pay attention to the effectiveness of assessment, can not become a mere formality. Department heads should attach importance to "three basics" training and often tell medical staff the importance of "three basics" learning, which is very important to improve the technical level of medical staff.
3. 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.
4. Further strengthen the monitoring of hospital infection.
It is necessary to make further efforts in monitoring hospital infection cases, disinfection and sterilization effects, and environmental health monitoring. , strictly implement the hospital infection management system, do the work carefully, can't 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.
5. Further strengthen the management of the use of antibacterial drugs.
According to the spirit of "Notice on Further Strengthening the Management of Clinical Application of Antibacterials" issued by the Ministry of Health, the specific implementation measures and reward and punishment system in our hospital were formulated, and the preventive medication during perioperative period was monitored. It is necessary to further implement the classification management system of antibacterial drugs, set prescription authority in outpatient workstations, and ensure the implementation of the system. Improve the rate of bacterial culture and drug sensitivity test to ensure the rational use of antibiotics.
Article 2 the clinical laboratory medical safety self-inspection report
According to the spirit of the Notice of Baoding Health Bureau on Printing and Distributing the Implementation Plan of Baoding's "Medical Quality Miles", the work of our department was self-examined, and it was considered that under the leadership of our hospital, the work of the laboratory department was gratifying, but there were also shortcomings, which needed to be continuously improved in the future work. 1, all comrades in the clinical laboratory earnestly study and practice Scientific Outlook on Development, adhere to people-oriented, patient-centered, pay attention to service links and detail management, and pay attention to improving their professional quality and moral cultivation. Can actively participate in the work of various departments, have a high understanding of medical quality and medical safety, pay attention to their own image, behavior, language, communicate sincerely with patients, and serve warmly. Correct use of civilized language, harmonious relationship with patients, won the praise of the majority of patients. There were no quarrels and medical disputes with patients.
2. Constantly improving service quality and ensuring medical safety are the core of our work, and various necessary systems have been formulated to urge everyone to comply with them. And constantly complement and improve in practical work.
3, able to carry out bacterial culture and drug sensitivity test, equipped with biosafety cabinets, incubators, autoclaves, ultraviolet disinfection and other equipment, and trained professionals are responsible for this work, with high biosafety awareness and work quality. Do not have the ability to detect highly pathogenic microorganisms.
4. The laboratory is equipped with various large-scale instruments and equipment: automatic biochemistry, five-classified blood cells, automatic blood coagulation instrument, biological safety cabinet, etc. , and establish the instrument file. Paying attention to the maintenance of the instrument at ordinary times can ensure the safe operation.
5. The fire escape is clear without obstacles.
6. There is no special room in the blood bank, which can be improved after the new building is completed, and the special blood storage refrigerator can be put in place in a few days.
In the future work, we will continue to work hard to continuously improve the quality of service, constantly improve various rules and regulations, and equip with special blood storage refrigerators, pulp dissolving machines and other equipment to better serve the majority of patients.
Article 3 the clinical laboratory medical safety self-inspection report
With the attention of hospital leaders, the whole hospital has carried out a comprehensive self-examination and self-correction work in view of the bad medical behaviors in some medical units at present. The clinical laboratory conducted a comprehensive self-examination and self-correction inspection on the management, quality, safety and service of the department. After three days of self-examination and self-correction, according to the relevant medical rules and regulations, some hidden dangers were found and relevant measures were formulated. The summary is as follows: 1. Most of the samples are qualified, and the unqualified samples are rejected and re-drawn. Existing problems: communication with the nursing department and various districts is not sufficient, and the quality problems existing in blood drawing should be reflected more comprehensively and timely. Measures: Report the quality of relevant samples to the nursing department in the form of tables every quarter to promote the quality improvement before inspection.
2. Indoor Quality Control All items can adhere to daily indoor quality control, with records, analysis and treatment of out-of-control points. Good quality control.
3. Room quality control can participate in various projects of Foshan and the Ministry of Health in Guangdong every year. There are records and feedback analysis, and there is strict control by the quality director. Similar analytical instruments regularly compare the measured values, and the data show that the measured results between different analytical instruments are within a reasonable and acceptable range.
4. All laboratories can seriously implement the critical value reporting system, and record and handle it. There is a problem, and it is found that the critical value of 1 holiday is not handled properly. Measures: Strengthen the study and training of employees' professional ability, and constantly improve their professional ability. Standardize and implement the processing and reporting of key values. Everyone is required to go through customs.
5. List of dangerous goods, safe electricity use and fire hazards. Dangerous goods should be locked for management and registered for use. No potential safety hazards were found in electricity and electrical appliances. No potential fire hazards were found. Fire fighting equipment is qualified and stored as required.
6. Service ability can send reports on time, and the timely rate of inspection reports reaches 95%. Service satisfaction reached 90%. The score is 84. The service level and quality should be continuously improved. Strengthen ideological and professional ethics education, establish a new industry style, and create a civilized service window.
This self-examination and self-correction examination plays a great role in improving the inspection quality of our department, and has positive significance in ensuring medical safety and eliminating medical hidden dangers.