Self-inspection report on hospital medical quality and safety

20 17 Hospital Medical Quality and Safety Self-inspection Report 1 In order to further improve medical quality and ensure medical safety, according to Lishui District? Strengthen the construction of medical ethics and guard against disputes between doctors and patients? As required by the monthly activity plan of special inspection (Li Wei Zi [20 17] No.81), in September of 2017, our bureau organized experts in medical treatment, nursing, hospital awareness, etc. to carry out inspection by consulting ledgers, taking medical records and on-site inspection. The relevant information is hereby notified as follows:

I. Work that has been carried out

The District People's Hospital conducts monthly departmental mutual inspection, random sampling, prescription review, rational use of antibiotics, formulates a special issue to inform the inspection results, and checks the implementation of medical measures through rounds and other forms, which has achieved certain results. Timely evaluation and analysis of doctor-patient disputes in district-level Chinese medicine hospitals plays a positive role in preventing doctor-patient disputes.

Second, the existing problems

(A) the quality and management of medical records

1. The medical record management in hospital operation is not standardized. Many medical records in the hospital are in a mess, and the inspection reports are also mixed. Even the examination report of the patient who was hospitalized for a week was not pasted in time. The admission ticket is printed with waste paper. The medical records of District Chinese Medicine Hospital lack the temperature list, doctor's advice list and doctor-patient communication record list.

2. The understanding and implementation of medical record writing norms are not in place. The descriptions of negative symptoms and symptoms in most medical records are lacking or insufficient; The record or description of the first course of disease is not standardized, and the content of differential diagnosis is lacking. Pay no attention to the results of abnormal auxiliary inspection, and there is no record of analysis and handling of abnormal results; English abbreviations such as kcl are included in the course records.

3. The connotation and quality of medical records need to be improved. The connotation and quality of the three-level ward round system are not high, and the records of ward rounds by higher-level doctors are a mere formality, which lacks the targeted analysis and guiding significance for the individual diagnosis and treatment plan of patients; Preoperative discussion is a mere formality, and there is no discussion on the indications of patients, the reasons for choosing surgical methods, the possible situations during and after operation and the countermeasures. The communication between doctors and patients is a mere formality, and the explanation of the diagnosis, treatment, prognosis and outcome of the disease is too simple and formatted, and there is no personalized expression of abnormal auxiliary results, new diagnosis after admission, important examination and treatment measures. There is a general lack of communication, and the communication about diseases is not thorough and clear.

Plagiarism is very common. For example, the content of superior doctors' rounds is almost the same as the first course record, and there is a large-scale plagiarism; The medical record and physical examination are the same as the first course record, and there is copying phenomenon;

5. There are still serious defects in medical records. All kinds of consent forms without patient's signature, lack of power of attorney or client's identity certificate.

(B) the implementation of the core system

1. The handover record is not timely or complete, or even blank.

2. Difficult, critical cases and death cases discussion system is not in place. In most wards, the discussion record book from June 5438 to September this year is blank or even missing.

3. The record of the third round is too simple and lacks analysis, which is of little guiding significance. The medical history, illness and treatment of hospitalized patients are not thorough and comprehensive, and there are defects in patient management and weak safety awareness.

4.？ Critical value? The reporting system has not been implemented. There is no analysis record during the course of the disease, no record of superior doctors' rounds, and no record of post-treatment review and treatment. Is this not reflected in the diagnosis and treatment process? Critical value? Clinical significance, right? Critical value? Not enough attention.

(3) Hospital infection management

The implementation effect of medical staff's hand hygiene compliance is not ideal, and a small number of staff have not mastered the standardized hand washing methods. Cotton swabs and infusion stickers can be seen on the ground and at the entrance of the infusion room.

(4) supervision and management of medical quality

Quality management at hospital and department level has not been effectively implemented. The Medical Quality Management Committee of the District Hospital of Traditional Chinese Medicine did not organize regular inspection and assessment as planned, and the functional departments did not regularly check the medical quality of the departments. Most clinical departments in two district-level hospitals did not carry out corresponding quality control activities and did not effectively manage the medical quality of the departments. The results of medical quality inspection and evaluation are not linked to performance appraisal.

Third, suggestions for the next step.

(a) Raising awareness and improving quality management systems at the hospital and departmental levels. Improve the quality management organization of hospitals and departments. Dean is the first person responsible for medical safety, and the director of clinical and medical department and head nurse are the first person responsible for quality management of the department. It is necessary to improve the understanding of the importance of medical quality work, strengthen internal supervision and management, fully mobilize the enthusiasm of those responsible for department management, and implement the division of responsibilities to everyone. The implementation of hospital and department quality management system, to achieve hierarchical management, clear rights and responsibilities, strict assessment, so that the hospital gradually moves towards standardized and scientific management.

(2) Strengthen quality control measures and intensify supervision and assessment. Pay attention to the core system of medical staff. Three basics and three strictness? As well as knowledge training on doctor-patient communication, so that everyone can be familiar with medical and health laws and regulations, master basic knowledge, basic theory and basic skills, and pay attention to doctor-patient communication. Strict implementation of the first diagnosis system, three-level physician rounds system, difficult case discussion system, critically ill patient rescue system, surgical grading management system, preoperative discussion system and other medical core systems, improve patient safety management, medical technology access, adverse event reporting, grading nursing and other rules and regulations. , and do a good job in implementation. Clear medical management objectives, formulate assessment rules, and form a working mechanism of irregular inspection and regular assessment.

(3) Pay attention to the application of medical quality inspection and evaluation results, and form a working mechanism for continuous improvement of medical care quality. Formulate medical quality management assessment and reward and punishment methods, and link the results of medical quality inspection and assessment with the benefit assessment, professional title appointment and annual assessment of departments and individuals, and reward the excellent and punish the poor.

In view of the weak links and defects found in the inspection, the hospital should draw inferences from others, carefully sort out the root causes, formulate feasible rectification plans and measures, clarify the division of responsibilities, implement the objectives and tasks, continuously improve the medical quality and service level, and better serve the people's health.

20 17 hospital medical quality and safety self-inspection report 2 supervision and guidance? Continuously improve quality and ensure medical safety? Themed? Does the medical quality go to Wan Li Road? Activity content: On February 2nd17th, February 2nd1-18th, the Municipal Health Bureau organized relevant experts to divide into three groups, and carried out activities in the second-level general hospitals in the city by listening to reports, checking information and on-site inspection. Does the medical quality go to Wan Li Road? Supervise and inspect the activities. The inspection work is now reported as follows.

I. Main achievements

County (city, district) health bureaus and medical institutions attach great importance to it? Does the medical quality go to Wan Li Road? Activities can be carried out in accordance with the unified deployment of the Municipal Health Bureau, highlighting key points, tackling difficulties, carrying out solid activities, and achieving remarkable results in all work.

(A) leadership attention, careful deployment

Can the county (city, district) health bureau and the leading bodies of medical institutions seriously organize the study for 20 1 1 year? Does the medical quality go to Wan Li Road? Activity plan, unify thoughts, raise awareness, and formulate the unit in combination with reality? Does the medical quality go to Wan Li Road? In the activity plan, an activity leading group was set up to strengthen organizational leadership, clarify the division of responsibilities and implement work responsibilities. The responsibility system and accountability system for the top leaders of medical institutions at all levels have been established to ensure? Does the medical quality go to Wan Li Road? The activity has achieved practical results. Xing 'an, Jishui, Wan 'an, Suichuan and other counties have formulated specific implementation plans in light of local conditions. On the basis of the measures for the convenience and benefit of the people introduced by the provincial department, they refined the measures for the convenience and benefit of the people and held a typical case review meeting.

(B) overall arrangements, and comprehensively promote

The inspected county (city, district) health bureaus and hospitals can overcome many difficulties in their busy work at the end of the year and make full preparations for this inspection. All localities and units have done it? Six combinations? Soon? Does the medical quality go to Wan Li Road? With what? Special rectification of clinical application of antibacterial drugs? Activities? Three good and one satisfied? Activities, the promotion of major public livelihood projects, the rectification of outstanding problems in the purchase and sale of medicines and medical services, the establishment of Ping An Hospital, and the development promotion year activities were combined to make overall arrangements and comprehensively promote.

(3) Pay close attention to implementation and ensure quality.

1. Medical safety awareness has been strengthened. Most hospitals can provide medical treatment for medical staff.

Quality, medical safety education and related training, improve medical staff's medical risk awareness and medical safety responsibility, strengthen medical ethics education, update quality and safety concepts, and improve quality management level. People's hospitals in Yongfeng, Anfu and Xiajiang counties have effectively improved the medical quality and safety awareness of medical staff through various publicity activities.

2. The quality of basic medical care has been further improved. Most hospitals can strictly implement the core system of medical quality and medical safety and standardize clinical diagnosis and treatment behavior; Can adhere to the patient-centered, attach importance to connotation construction, and continuously improve the quality of medical care; It can carry out quality training and competition activities in basic clinical skills, clinical laboratory skills, hospital infection control skills and medical records, improve the professional quality and basic skills of medical teams, and emerge a number of outstanding models. Taihe County People's Hospital has clear classification of surgeons and doctors, clear supervision and punishment, good medical record quality and good results in clinical basic skills competition.

3. Various management systems have been improved and implemented. Most hospitals can initially establish scientific, reasonable and operable medical quality and safety management systems and measures in combination with their actual conditions. Yongxin County, suichuan county, Jishui County People's Hospital and the First People's Hospital of the city have sound rules and regulations, and focus on the improvement and implementation of key and core systems in view of the weak links in hospitals.

4. The burden of medical expenses for the masses has been lightened. Most hospitals can vigorously carry out special rectification activities such as antibacterial drugs, clinical pathway management, high-quality nursing projects, mutual recognition of examination results of medical institutions at the same level and cost control of single diseases, so as to promote reasonable clinical examination and diagnosis and treatment and reduce the burden of medical treatment for the masses. County People's Hospital has a solid clinical pathway management work; The special rectification activities of antibacterial drugs in Taihe County and Xingan County People's Hospital have achieved remarkable results; County, Taihe county quality nursing project actively carried out.

5. The satisfaction of the masses has been continuously improved. Most hospitals can better implement the Notice of the Ministry of Health on Further Improving the Management of Medical Services in Medical Institutions and the ten measures of medical services for the convenience and benefit of the people issued by the ministries and agencies, regard improving people's feelings of seeing a doctor as the innovation and breakthrough point of strengthening medical services, push forward various measures to improve medical services in a planned and focused manner, and better achieve reasonable diagnosis and treatment arrangements, enthusiastic service and smooth process, which further promotes the improvement of medical services.

Second, the main problems

This inspection found that although it passed? Does the medical quality go to Wan Li Road? Activities, the city's secondary comprehensive medical institutions medical quality and safety management level has been greatly improved, but at the same time, there are still weak links in the quality of basic medical care, medical safety still exists security risks.

1. Ideological understanding needs to be strengthened. The level of medical quality and safety management in different places is unbalanced, and a few local health administrative departments pay insufficient attention to it. Does the medical quality go to Wan Li Road? The activity was not implemented in the actual work, but simply forwarded the implementation plan issued by the Municipal Health Bureau, and the work remained literal. In some places, medical institutions have not been organized to carry out self-examination and supervision before the inspection. The leading bodies of some hospitals don't know enough about medical quality and safety, and they don't study medical quality and safety management. The management of medical quality and safety in a few hospitals is relatively weak.

2. It is necessary to strengthen the implementation of the core medical system. In the process of pursuing development, some hospitals simply emphasize the increase of disease sources, the expansion of beds, the investment of equipment and the improvement of housing facilities, ignoring the talent reserve and standardized training, and the implementation of the core system needs to be strengthened. Difficult and critical cases and death cases are not discussed in time, and there are few rectification suggestions in the discussion of death cases, and the conclusive opinions are vague; Preoperative discussion, evaluation and pre-anesthesia evaluation are not in place, and there are great hidden dangers in medical quality and safety. The core systems such as the three-level doctor's ward round system and the handover system have not been effectively implemented and become a mere formality; There are misunderstandings in surgical grading management, and authorization and dynamic management are not strictly carried out in accordance with provincial and provincial surgical grading management norms and surgical grading catalogues; ? Three basics and three strictness? The training is not standardized; The emergency plan, equipment and medicines for critically ill patients are incomplete.

3. The special rectification of antibacterial drugs needs to be strengthened. Although some hospitals have set up special management teams for antibacterial drugs, the division of labor is not clear, the rectification work has no progress requirements, and the liability form has not formulated different control indicators according to different departments; Preventive use of antibiotics in clean surgery is still on the high side, and the utilization rate of antibiotics is higher than the requirements of the Ministry of Health. The problem of unreasonable selection of antibacterial drugs is more prominent, and the application rate of the third generation cephalosporins is higher; The setting of third-line personnel in classified catalogue and classified management is unreasonable; The classified management of antibacterial drugs is not in place, and doctors use antibacterial drugs beyond their authority; Bacterial drug resistance monitoring is not targeted; The microbial culture of inpatients is not standardized; Stop taking medicine within 24 hours after operation, especially in orthopedics, cardiology and brain surgery. In addition to strengthening supervision, including rewards and punishments, we should also strengthen professional learning, find academic basis and build confidence.

4. Quality nursing service needs to be strengthened. Nurses in some hospitals don't fully understand the connotation and essence of high-quality nursing, and the way to divide responsibilities is not clear. There is a phenomenon of division of functions in scheduling, and there is a nursing scheduling method that cannot reflect the continuous service of responsible nurses to patients. Nurses have no sense of active service; Nurses do not have a comprehensive grasp of patients' condition, and basic nursing is not in place; Insufficient nursing staff; The needs of patients in individual wards are inconsistent with the ability of responsible nurses, the content and concept are lagging behind, and the overall nursing requirements of responsibility system are not updated in time; The grading standards and job responsibilities of nurses are not clear or some responsibilities overlap; The head nurse is busy with daily work, and the responsible nurse relies on the team leader to guide and care for the patients, which forms the phenomenon of independent management of patients at all levels.

5. The behavior and process of diagnosis and treatment need to be improved. The layout and process of emergency departments in some hospitals are unreasonable, and the emergency medical staff are highly mobile, with few personnel, outdated first-aid equipment, no observation bed, and unskilled basic techniques such as cardiopulmonary resuscitation, which have medical hidden dangers; The area where the pathology department is located does not meet the requirements, the layout is unreasonable, and there is no ventilation and exhaust facilities; The layout of disinfection supply center is unreasonable; ? Treatment first, then reconciliation? Planned, not implemented; The proportion of appointment registration is not up to standard, and there is no unified hospitalization inspection system; The identification of critically ill patients is unclear, and the surgical patients have no wristband identification; The statistical concepts of access rate, variation rate and completion rate of clinical pathway are vague, the methods are not unified, the admission rate is low, the hospital level is out of touch with the departments in management, and the evaluation, analysis and improvement of variation factors are insufficient; The first type of technical audit is not standardized, the catalogue is incomplete and the number is unclear.

6. Hospital infection management needs to be strengthened. Some hospitals have not set up an independent hospital infection department, and there are insufficient full-time hospital infection management personnel, most of whom are nurses, and the affiliation of personnel is unknown, so it is difficult to carry out their work strictly in accordance with the norms. The isolation of patients infected with multi-drug resistant bacteria in some hospitals is not in place, and the targeted monitoring of multi-drug resistant bacteria, the monitoring of antimicrobial sensitivity and drug resistance mode, the monitoring of high-risk links and factors of nosocomial infection and clinical intervention are not in place; Some county hospitals failed to manage ventilator-associated pneumonia infection, urinary tract infection caused by indwelling catheter and primary blood-borne infection caused by central venous catheter. In a few hospitals, hemodialysis wards are not strictly divided into clean areas, relatively polluted areas and polluted areas, and there are mixed functional areas, so dialysis treatment rooms are not set up. The layout of neonatal ward is unreasonable, the bed density is too high, and the bed spacing does not meet the requirements; Some county-level hospitals have not set up ICU and neonatal ward, and the phenomenon of combining maternal and child rooms with neonatal rooms is prominent. There is no strict infection isolation zone, no infection isolation ward in neonatal ward, and protective isolation measures are not in place.

7. Hospital management and discipline construction need to be strengthened. The management system of some hospitals is not standardized and perfect, and there is no record of the implementation process, so it is impossible to monitor the implementation and effect; The technical operation procedures and job responsibilities of personnel at all levels are not clear enough; The summary and analysis of mistakes and accidents and the implementation of rectification are not effective; Part of the system is limited to the text level and has not been really realized; The phenomenon of extra bed is serious. According to the actual opening of beds, there is a serious shortage of personnel, and medical staff have been overworked for a long time, which has great security risks. The scale has been greatly expanded, but the department management and medical quality are lagging behind. Some hospitals attach importance to the income generation of departments and weaken the discipline construction. In the emergency department and anesthesiology department of a few hospitals, there are not enough beds, professionals, professional knowledge and skills, so they can't complete the first aid and severe rescue tasks well. Most county hospitals do not have ICU wards and anesthesia recovery beds.

Third, the job requirements

1. Raise awareness and strengthen leadership. Health administrative departments at all levels and medical institutions at all levels should further strengthen development? Does the medical quality go to Wan Li Road? And then what? Special rectification of clinical application of antibacterial drugs? The enthusiasm, initiative and creativity of other activities, overcome the war-weariness mood, closely combine with the reality, conscientiously implement the work requirements, make practical moves, seek practical results, and promote the continuous deepening of activities.

2. Pay attention to propaganda and guide public opinion. Health administrative departments at all levels and medical institutions at all levels should continue to communicate and negotiate with the news media, vigorously publicize the new progress and experience made by hospitals in strengthening medical quality management, ensuring medical safety and providing quality medical services, publicize and report advanced figures and deeds, set up advanced models, and create a good medical environment for medical workers.

3. lay a solid foundation and focus on implementation. Health administrative departments at all levels and all kinds of medical institutions at all levels should track the common problems found in the inspection, urge the rectification, and achieve? Six realization? That is, to implement rectification items, rectification measures, rectification time limit, rectification effect, contractors and responsible personnel, earnestly safeguard the medical safety of the people, and gradually establish a long-term supervision mechanism to ensure long-term unremitting efforts and achievements.

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