2012年科室患者安全目标

2012年科室患者安全目标 患者安全目标 一:严格执行查对，提高医务人员对患者身份识别的准确性。 二:严格执行在特殊情况下医务人员之间有效沟通的程序，做到正 确、执行医嘱。 三:严格执行手术安全核查制度和流程，防止手术患者、手术部位 及术式错误。 四:严格执行手卫生，落实医院感染控制的基本要求。 五:提高用药安全。 六:建立临床实验室“危急值”报告制度。 七:防范与减少患者跌倒事件发生。 八:防范与减少患者压疮发生。 九:主动报告医疗安全(不良)事件。 十:鼓励患者参与医疗安全。 implementation of risk mortgage, and then signed by the project managers project quality responsibility, determine some quality goals. Layers of signing responsibility system in order to facilitate the achievement of quality goals. 3.1.3 development project five control line: the basic line of control, body control line control line, decoration, civilization, scene safety control lines, each line that you want to charge, and linked with the economic, do put in place bonus in cash. 3.1.4 establishment of total quality management: key for the project and the use of new technologies, new processes and carries out mass of QC group activity, set up a QC group, QC methods benefit from scientific and technological progress to quality, to schedule,. 3.1.5 a veto construction quality. 3.2 establish and strictly enforce the system. Implementation of construction site engineering technical management accountability, rigorous scientific attitude and hard work style set strict demands on themselves, strictly carry out the technical regulations of the Corporation, scientific organization of the technical work, establishment of normal work order, work focus to improve technical management of project quality, shorten and improve the economic benefit of the specific business. 3.2.1 establishment of construction organization design and construction plan review: pre-construction preparation and 由于医院管理理念的进步和病人自主意识的增强，患者安全问题已经引起世界卫生组织及众多国家医务界的高度关注。世界卫生组织(WHO)多次呼吁各成员国密切关注患者安全，提出全球共同努力，开展保证患者安全的行动。采取多种有效措施，积极开展保障患者安全活动，足见对医疗安全、患者生命安全的高度重视。 严格执行十大安全目标，保证护理安全，也是保证我们自己的安全～ 医疗安全的核心和目的首先是病人安全。“病人安全“的提法直观地体现“以病人为中心”的理念.病人安全是当前医学研究和医疗实践的重要课题,也是世界卫生组织(WHO)2006年启动的一项全球性工作。关注病人安全,共创医患关系双赢的局面. 对照标准认真查找隐患和不足，结合各科室专业特点，对存在安全隐患的关键环节，设置标识，提示医务人员杜绝麻痹大意的思想，防止不良事件发生 安全管理的终极目标就是保障患者安全，而创建病人安全文化是一个重要前提。 医疗安全是医患双方的共同责任，充分体现患者的权利，与以患者为中心的服务理念 目标一:严格执行查对制度，提高医务人员对患者身份识别的准确性。 1、进一步落实各项诊疗活动的查对制度，在抽血、给药、或输血时，至少同时使用两种患者识别方法，不得仅以房号作为识别依据。开展请病人说出自己名字，后再次核对的确认病人姓名的方法。 2、在实施任何介入或有创高危诊疗活动前，责任者都要主动与患者或家属沟通，作为最后确认的手段，以保证正确的患者，实施正implementation of risk mortgage, and then signed by the project managers project quality responsibility, determine some quality goals. Layers of signing responsibility system in order to facilitate the achievement of quality goals. 3.1.3 development project five control line: the basic line of control, body control line control line, decoration, civilization, scene safety control lines, each line that you want to charge, and linked with the economic, do put in place bonus in cash. 3.1.4 establishment of total quality management: key for the project and the use of new technologies, new processes and carries out mass of QC group activity, set up a QC group, QC methods benefit from scientific and technological progress to quality, to schedule,. 3.1.5 a veto construction quality. 3.2 establish and strictly enforce the system. Implementation of construction site engineering technical management accountability, rigorous scientific attitude and hard work style set strict demands on themselves, strictly carry out the technical regulations of the Corporation, scientific organization of the technical work, establishment of normal work order, work focus to improve technical management of project quality, shorten and improve the economic benefit of the specific business. 3.2.1 establishment of construction organization design and construction plan review: pre-construction preparation and 确的操作。 3、完善关键流程识别措施，即在关键的流程中，均有患者识别准确的具体措施，交接程序与文件。 4、建立使用“腕带”作为识别标识制度，在诊疗活动中使用“腕带“，作为各项诊疗操作前辩识病人的一种手段。 目标二:严格执行在特殊情况下医务人员之间有效沟通的程序，做到正确、执行医嘱。 1.正确执行医嘱，不使用口头或点电话知的医嘱。 2.只有在对危重症患者紧急抢救的特殊情况下，对医师下达的口头临时医嘱、护士应向医生重述，在执行时实施双重检查。 3.接获口头或电话通知的患者“危急值”或其他重要的检验结果时，接获者必须规范，完整地记录检验结果和报告者的姓名与电话，进行复述确认无误后方可提供医师使用。 目标三:严格执行手术安全核查制度和流程，防止手术患者、手术部位及术式错误。 1建立与实施手术前确认制度与程序，有交接核查表，以确认手术必须的文件资料与物品(如病历、影象资料、术中特殊用药等)均以备妥。 2建立术前由手术医师在手术部位作标识的即刻停制度与规范，并主动邀请患者参与认定，避免错误的部位、错误的病人、实施错误的手术。 目标四:严格执行手卫生规范，落实医院感染控制的基本要求。 1制定并落实医护人员手部卫生和手部卫生实施规范，培植有效、便捷的手卫生设备和设施。为执行手部卫生提供必要的保障。 2制定并落实医护人员手术操作过程中使用无菌医疗器械规范，implementation of risk mortgage, and then signed by the project managers project quality responsibility, determine some quality goals. Layers of signing responsibility system in order to facilitate the achievement of quality goals. 3.1.3 development project five control line: the basic line of control, body control line control line, decoration, civilization, scene safety control lines, each line that you want to charge, and linked with the economic, do put in place bonus in cash. 3.1.4 establishment of total quality management: key for the project and the use of new technologies, new processes and carries out mass of QC group activity, set up a QC group, QC methods benefit from scientific and technological progress to quality, to schedule,. 3.1.5 a veto construction quality. 3.2 establish and strictly enforce the system. Implementation of construction site engineering technical management accountability, rigorous scientific attitude and hard work style set strict demands on themselves, strictly carry out the technical regulations of the Corporation, scientific organization of the technical work, establishment of normal work order, work focus to improve technical management of project quality, shorten and improve the economic benefit of the specific business. 3.2.1 establishment of construction organization design and construction plan review: pre-construction preparation and 手术后的废弃物应当遵循医院感染控制的基本要求。 目标五:提高用药安全。 1、建立病房药柜内的药品存放、使用、限额、定期检查的规范制度;存放毒、剧、麻醉药有管理和登记制度，符合法规要求。 2、病房存放高危药品有规范，不得与其他药物混合存放，高浓度电解质制剂(包括氯化钾、磷化钾及超过0.9%的氯化钾等)肌肉松弛剂与细胞毒等高危药品必须单独存放，有醒目标志。 3、病区药柜的注射药、内服药与外用药严格分开放置，有菌无菌物品严格分类存放，输液处置用品备用物品、皮肤消毒剂与空气消毒剂、物品消毒剂严格分类分室存放管理。 4、所有处方或用药医嘱在转抄和执行时，都有严格的二人核对、签名程序，认真遵循。 5、在下达与执行注射剂的医嘱(或处方)时要注意药物配伍禁忌。 6、病房建立重点药物用药后的观察制度与程序，医师、护师须知晓这些观察制度和程序，并能执行。对于新药特殊药品要建立用药前的学习制度。 7、药师应为门诊患者提供合理用药的方法及用药不良反应的服务指导。 8、进一步完善输液安全管理制度，严把药物配伍禁忌关，控制静脉输液流速，执行对输液病人最高滴数限定告知程序，预防输液反应。 目标六:建立临床实验室“危急值”报告制度。 implementation of risk mortgage, and then signed by the project managers project quality responsibility, determine some quality goals. Layers of signing responsibility system in order to facilitate the achievement of quality goals. 3.1.3 development project five control line: the basic line of control, body control line control line, decoration, civilization, scene safety control lines, each line that you want to charge, and linked with the economic, do put in place bonus in cash. 3.1.4 establishment of total quality management: key for the project and the use of new technologies, new processes and carries out mass of QC group activity, set up a QC group, QC methods benefit from scientific and technological progress to quality, to schedule,. 3.1.5 a veto construction quality. 3.2 establish and strictly enforce the system. Implementation of construction site engineering technical management accountability, rigorous scientific attitude and hard work style set strict demands on themselves, strictly carry out the technical regulations of the Corporation, scientific organization of the technical work, establishment of normal work order, work focus to improve technical management of project quality, shorten and improve the economic benefit of the specific business. 3.2.1 establishment of construction organization design and construction plan review: pre-construction preparation and 1.“危急值”项目至少应包括有:血钙、血钾、血糖、血气、血小板计数，白细胞计数，凝血酶原时间，活化部分凝血活酶时间等。 2.“危急值”报告重点对象是急诊科、手术室，各类重症监护病房等部门的急、危重症患者。 3.对属“危急值”报告的项目实行严格的质量控制，尤其是分析前质量控制措施，如应有标本采集、储存、运送、交接、处理的规定。 目标七:防范与减少患者跌倒事件发生。 1.对体检、手术和接受各种检查与治疗患者，特别是儿童、老年、孕妇、行动不便和残疾患者，用语言提醒、搀扶、请人帮助或警示标识等办法防止患者跌倒事件的发生。 2.认真实施跌倒防范制度并建立跌倒报告与伤情认定制度。 3做好基础护理，要配好用好护理人力资源，开放床位与病房，上岗护士配比为1;0.4。如果人力配备不足，管理者应及时进行人力危机值报告制度。 目标八:防范与减少患者压疮发生。 1.认真实施有效的压疮防范制度与措施。 2.落实压疮诊疗与护理规范实施措施。 目标九:主动报告医疗安全(不良)事件。 医疗不良时间报告对于发现不良因素、防范医疗事故、保证医疗安全，促进医学发展和保护患者利益是有益的;可有效的避免医疗缺陷;可增加医疗水平和服务的透明度。 1医院要倡导主动报告不良事件。有鼓励医务人员报告的机制。 2积极参加中国医院协会自愿、非处罚性的不良事件报告系统，为行业的医疗安全提供信息。 implementation of risk mortgage, and then signed by the project managers project quality responsibility, determine some quality goals. Layers of signing responsibility system in order to facilitate the achievement of quality goals. 3.1.3 development project five control line: the basic line of control, body control line control line, decoration, civilization, scene safety control lines, each line that you want to charge, and linked with the economic, do put in place bonus in cash. 3.1.4 establishment of total quality management: key for the project and the use of new technologies, new processes and carries out mass of QC group activity, set up a QC group, QC methods benefit from scientific and technological progress to quality, to schedule,. 3.1.5 a veto construction quality. 3.2 establish and strictly enforce the system. Implementation of construction site engineering technical management accountability, rigorous scientific attitude and hard work style set strict demands on themselves, strictly carry out the technical regulations of the Corporation, scientific organization of the technical work, establishment of normal work order, work focus to improve technical management of project quality, shorten and improve the economic benefit of the specific business. 3.2.1 establishment of construction organization design and construction plan review: pre-construction preparation and 3形成良好的医疗安全文化氛围，提倡非处罚性、不针对个人的环境、有鼓励员工积极报告威胁病人安全的不良事件的措施。 4医院能够将安全信息与医院实际情况相结合，从医院管理体系上，从运行机制上、从规章制度上进行有针对性的持续改进，医院每年至少有两件系统改进。 目标十:鼓励患者参与医疗安全。 1.主动邀请患者参与医疗安全管理，尤其是患者在接受手术、介入或有创操作前告知其目的和风险，并请患者参与手术部位的确认。 2.药物治疗时，告知患者用药目的与可能的不良反应，邀请患者参与用药时的查对。 3.告知患者提供真实病情和真实信息的重要性。 4.护士在进行护理和心理服务时，应告知如何配合及配合治疗的重要性。 implementation of risk mortgage, and then signed by the project managers project quality responsibility, determine some quality goals. Layers of signing responsibility system in order to facilitate the achievement of quality goals. 3.1.3 development project five control line: the basic line of control, body control line control line, decoration, civilization, scene safety control lines, each line that you want to charge, and linked with the economic, do put in place bonus in cash. 3.1.4 establishment of total quality management: key for the project and the use of new technologies, new processes and carries out mass of QC group activity, set up a QC group, QC methods benefit from scientific and technological progress to quality, to schedule,. 3.1.5 a veto construction quality. 3.2 establish and strictly enforce the system. Implementation of construction site engineering technical management accountability, rigorous scientific attitude and hard work style set strict demands on themselves, strictly carry out the technical regulations of the Corporation, scientific organization of the technical work, establishment of normal work order, work focus to improve technical management of project quality, shorten and improve the economic benefit of the specific business. 3.2.1 establishment of construction organization design and construction plan review: pre-construction preparation and