Summary of medical quality and safety work 1

The first is to effectively improve medical services.

Strengthen the education of medical ethics and medical laws and regulations, so that the broad masses of workers can further establish the idea of serving patients wholeheartedly, adhere to the service concept of "patient-centered", earnestly carry out the "three good and one satisfied" activities with the content of "good service, good quality, good medical ethics and satisfaction of the masses", and continuously improve the level of medical services. Innovating service process and optimizing diagnosis and treatment environment. Enrich outpatient doctors, arrange working hours reasonably, insist on opening clinics on time, and ensure patients to see a doctor in time. The establishment of an open and transparent system of medical expenses and the implementation of a daily list system of inpatients are very popular among patients, which is convenient for patients to inquire about the details of drug prices and hospitalization expenses at any time.

Strengthen communication between doctors and patients, improve communication content, improve communication methods, pay attention to communication effect, strengthen basic hospital management, establish and improve medical safety management organizations, implement various core medical work systems and safety measures, ensure the legal, reasonable and safe use of medical instruments and equipment, and avoid medical errors and accidents. Strict technology access system, standardize medical behavior. Conscientiously implement the Drug Administration Law and the Regulations on the Supervision and Administration of Medical Devices, and strengthen the supervision and administration of the procurement, storage and use of drugs and medical devices.

Second, improve the quality of medical services.

Medical quality and safety is related to people's health and safety, is the lifeline of medical services, and is the core content and eternal theme of hospital management. To carry out medical safety, we must first improve medical quality and service level. Strengthen medical quality management, pay close attention to the implementation of rules and regulations, always adhere to the "patient-centered", take quality as the core, take quality and safety as the theme, conscientiously implement various rules and regulations, post responsibilities, strictly implement the routine of diagnosis and treatment, and implement various systems in all aspects.

Set up the medical quality management team of xx Town Health Center, strengthen the quality management of medical documents, strictly implement the basic norms of medical record writing, and monitor and manage the quality of medical records throughout the process. Formulate the assessment plan for professional and technical personnel in xx Town Health Center, implement the reward and punishment mechanism, ensure that rewards and punishments are in place, and give praise and material rewards to departments or individuals with excellent medical service quality assessment results; For departments or individuals whose medical service quality assessment results are not up to standard, in addition to economic punishment and hospital informed criticism, they should also strengthen the training of "three basics and three strictness", hold three basics assessments for all kinds of personnel at all levels from time to time, comprehensively evaluate the clinical theoretical knowledge level and practical operation skills of medical staff, and link the assessment results with personal assessment to ensure the continuous improvement and update of medical technicians' own technical quality and comprehensively improve their professional quality.

Three, establish a sound quality management system, standardize medical behavior is the core.

This year, our hospital started with strengthening the system construction, combined with the nature and content of each post, formulated the relevant management system and assessment rules, and formulated the comprehensive target responsibility letter of functional departments and business departments, realizing the pattern of first-level management and first-level responsibility. Clear responsibilities, ensure clear functions, clear powers and responsibilities, and moderate benefits, so as to realize rule-based management and gradually improve the legalization, institutionalization, standardization and standardization of management.

Fourth, properly handle disputes between doctors and patients according to law.

According to relevant laws and regulations, the disposal of disputes between doctors and patients should be brought into the legal and standardized track to safeguard the legitimate rights and interests of both doctors and patients. According to "Regulations on Handling Medical Accidents", a medical dispute coordination and handling team of xx Town Health Center was established to properly handle medical disputes according to law. Adhere to the principle of prevention first, early detection and small disposal, establish and improve the prevention and disposal mechanism of doctor-patient disputes, conscientiously implement relevant prevention and control measures, and strive to resolve all kinds of doctor-patient disputes to prevent mass incidents and vicious incidents caused by doctor-patient disputes.

Five, strengthen security measures to ensure hospital safety.

Organize regular training for personnel in key positions and implement various internal safety measures. Conduct a comprehensive inspection of fire safety on a regular and irregular basis, focusing on places that are prone to fire, store dangerous goods and concentrate people (such as pharmacies, clinics and wards). ), and regular maintenance and replacement of fire fighting facilities, to ensure that fire fighting equipment is in good condition. Our hospital implements the general duty system of hospital leaders, defines the division of time for each person, carries out the inspection of the whole hospital during the duty, and earnestly implements the public security preventive measures such as fire prevention, theft prevention and sabotage prevention. Strictly implement the safety responsibility system, do a good job in the investigation of unstable factors, and immediately rectify the problems found. Formulate emergency measures for civil air defense, physical defense and technical defense to ensure that major safety accidents do not occur in hospitals.

Summary of medical quality and safety II

20xx is an important year for xxXX Hospital in XX City to establish a third-class first-class hospital. Over the past year, we have gained a comprehensive, brand-new and deeper understanding of medical quality and safety. Now, the work of neurology in medical quality and safety in the past 20xx years is summarized as follows:

1. We made a work plan at the beginning of 20xx, that is, 1 and February, and made overall arrangements for the work priorities of 20xx 1 to 12. The specific work should be carried out to everyone, and the implementation of various core systems should be checked regularly or irregularly, and corresponding rectification measures should be put forward. Under the leadership of the relevant functional departments of the hospital, we have continuously studied and improved the communication system between doctors and patients (including the first communication after admission, the communication between doctors and patients before discharge, and the communication at any time when the condition changes), evaluated the condition of patients who have been hospitalized for more than 30 days, formulated the clinical diagnosis and treatment guidelines, operating specifications and operating procedures of neurology, improved the pharmaceutical affairs management (especially the management of antibiotics), the supervision of multiple drug resistance, the management and processes of single diseases and clinical pathways, and established and improved the departments.

Second, the implementation of medical record quality control. 20xx years ago, the supervision of medical record quality in our department was mainly based on regular or irregular spot checks of medical records, and the inspection results were recorded in the self-inspection register of medical record quality. Found the problem, put forward in the morning meeting, realize * * * improvement and improvement. After 20xx years, we graded the quality of inpatient medical records according to the new grading standards issued by the Medical Department. In one year, * * * randomly selected more than 100 medical records, and there were no Class B and Class C medical records. * * * Examining 577 medical records filed in 20xx10-June, it was found that the three-level doctor's ward round system was implemented, but it was not implemented in place, the medical records were altered, the communication between doctors and patients was not signed, and the writing quality of course records was not high. For example, there are too few problems such as the development and change, prognosis and differential diagnosis of diseases, which will be gradually rectified after July 20xx.

Third, the supervision of antibacterial drugs. According to the situation of our department, in order to achieve the relevant goals issued by the hospital, we strictly implement the hierarchical management of antibacterial drugs, organize the study and evaluation in the department for many times, and strictly implement the indications for the use of antibiotics. Our department successfully completed the goal issued by the hospital, that is, the intensity of antibiotic use was below 20DDD. Over the past year, the intensity of antibiotic use in our department has been 9- 12DDD, and the norms and procedures for restricting the use of antibiotics have been strictly implemented. The use of super-grade antibiotics is based on the drug sensitivity results, and the application for pharmacy consultation is made before use. However, due to ignorance of this work, 1 case did not apply for consultation, and only selected drugs according to drug sensitivity results. Within one year, the inpatient department of neurology department will register the use of antibacterial drugs (including dosage, dosage form and usage) of discharged patients. According to the statistics of the total number of outpatients who use antibacterial drugs every day, less than 20% outpatients use antibacterial drugs.

In the above work, antibacterial drugs were not submitted for inspection in time before use. The main reason is the infection of patients after admission, and sending them for examination may affect and delay the opportunity of diagnosis and treatment.

Fourth, implement three basics and three strictness training. Since July of 20xx, the training plan of "three basics and three strictness" has been formulated, and the training standards have been formulated. The procedures of unarmed cardiopulmonary resuscitation, lumbar puncture and physical examination scoring standards have been trained in departments.

Five, the quality control of single disease and clinical pathway. Up to now, our department has brought acute cerebral infarction, viral encephalitis and status epilepticus into the single disease management and clinical pathway. To sum up, there were 9 1 case of acute cerebral infarction in our department in 20xx, and the average hospitalization expenses were 14 100 yuan and the average hospitalization days were 14.2 days. Seven patients with viral encephalitis were included in clinical pathway management, and 0 patients were in status epilepticus. To sum up, status epilepticus and viral encephalitis are less in this group. The number of direct network reports of single diseases is small, which is only three months after the installation of computers in our department, and our doctors do not pay enough attention to direct network reports.

Sixth, the summary of teaching quality control. In 20xx, our department received 72 interns, including 4 general practitioners transferred for training, 2 in xx Medical College, 34 in xx College of Traditional Chinese Medicine, and 3 in xx Medical College. * * * 16 Lecture of the Department of Histology, covering physical examination and nervous system anatomy, diagnosis and treatment of cerebral hemorrhage, cerebral infarction, subarachnoid hemorrhage and epilepsy.

Seven, hand hygiene, hospital feeling, multidrug resistance work summary. Since June of 20xx, our department has carried out and participated in many trainings on hand hygiene, nosocomial infection and multidrug resistance in the hospital. So far, our department has carried out a self-examination, and the examination of hand hygiene and related knowledge and multidrug resistance has reached the standard.

Eight, the research and implementation of blood transfusion system. In 20xx, our department carefully organized and participated in the in-hospital blood transfusion knowledge training 1 time, studied in the department for nearly1time, earnestly studied the indications of blood transfusion, filled in the blood transfusion application form, evaluated and implemented the blood transfusion doctor's advice before and after blood transfusion. In 20xx, two patients in * * * Department of our hospital received autologous blood transfusion. After self-examination, the blood transfusion medical record score was above 90 points.

Nine, the implementation of the discussion system. Our department has always adhered to the discussion of difficult medical records, critical cases and death cases, and established and improved the evaluation and discussion system for hospitalization for more than 30 days this year. In 20xx, our department died 1 person, and the discussion record was made in our department. Difficult cases were discussed 5 times, critical cases were discussed 1 case, and 70 cases were hospitalized for more than 30 days. Write and record in time in strict accordance with the case discussion system. In which 10 report takes more than 30 days to fill in.

X. implementation of critical value reporting system. Since May of 20xx, * * * has received 36 critical value reports. After self-examination by hospitals and departments, the registration was missed once on July 22nd, 20xx. The critical value is that the patient Li (2364 17) has detected G+ positive bacteria in blood culture, which has been studied by the department, and the party concerned has been punished and corrective measures have been formulated.

Eleven, establish and improve the multi-drug resistant bacteria (Ⅱ) registration and related systems. The inpatient transfer register * * * is transferred to 5 1 patient (from June of 20xx, 2 1). In 20xx, our department reported multidrug-resistant bacteria (Class Ⅱ) 1 case. Klebsiella was detected in sputum culture, and corresponding measures such as bedside isolation, special equipment and strict hand hygiene have been taken. At present, the patient has improved and been admitted to hospital.

Twelve, establish and improve the unplanned enrollment and resumption of registration evaluation system. Since May of 20xx, * * * there have been two unplanned returns. Zhao Guoshu (2453 18) was diagnosed with cerebral infarction in the recovery period and returned 8 days after discharge. The reason for the follow-up visit is that the patient hopes that the limb function will recover better and the vascular disease will not recur. Xiao Huaixue diagnosed multiple intracranial space occupying lesions (brain metastasis? ), the patient went to xx for treatment, and the superior department had no hospital bed, so it was returned.

Thirteen, improve the patient discharge follow-up system and further implement. Among them, nurses followed up more than 70 cases and doctors followed up 15 cases. At present, the number of cases followed up by doctors in our department is small, mainly due to the lack of follow-up awareness, and some follow-up patients have missed registration. At present, our department has been equipped with public mobile phones, and it is necessary to further strengthen and implement the follow-up system for discharged patients.

XIV. Improve the reporting system of adverse events. In 20xx, our department reported 4 cases of adverse events 1 case, including water and electricity adverse events 1 case, wall pollution1case, 3 cases of nursing adverse events and 9 cases of drug adverse events. The main analysis reasons are: high-risk patients fall off the bed. Adverse drug events involved carbamazepine, ampicillin, amoxicillin, flucloxacillin, cefmetazole and other drugs. The main symptoms were rash, skin itching and digestive tract adverse reactions, which were all cured after antiallergic treatment.

Fifteen, formulate and improve the complaint and management mechanism. In 20xx, two patients complained in our department. On September 4th, 20xx, xxx's family complained that the needle water was wrong. Our department adopts self-examination to implement the situation and reports it to the nursing department and the medical department. After the implementation, criticize, educate and punish the parties concerned. On October 7th, 20xx65438+/kloc-0, patient xxx complained that the blood pressure control was not ideal, the focus of cerebral infarction did not disappear, and the cough did not improve. The department organized the whole group of doctors to make rounds, analyzed the reasons, adjusted the treatment plan, and explained to the patients that the infarct could not disappear. Invited xxx, director of respiratory department, to consult and assist in the diagnosis and treatment of respiratory diseases, and the patient got better and was discharged from hospital.

To sum up, we have done a lot of work in medical quality control under the leadership of hospital leaders and relevant departments and through the joint efforts of all medical staff during the 20xx years when the number of hospital beds has obviously increased and the workload has increased. But to sum up, there are still many aspects that have not been put in place, and there are still many shortcomings in details. For example, the awareness rate of the core system and the implementation of relevant systems need further efforts. Next year, we will strive to do more work in single disease management, hand hygiene, doctor's advice and case quality supervision in the follow-up of discharged patients, and strive to improve the medical quality of our department.

Summary of medical quality and safety work III

In 20xx, according to the work plan of the hospital medical quality and medical safety management committee, a number of goals were formulated and implemented. But there are still many shortcomings, which need to be improved and perfected in the future work. 20xx's management of medical quality and medical safety is summarized as follows:

First, implement management according to law.

In order to further strengthen the implementation and implementation of legal practice and ensure medical safety, the Medical Department has strengthened the inspection, supervision, implementation, feedback, organizational learning and implementation of legal practice in the whole hospital. To strengthen the management of practice access, the directors of various disciplines are required to strictly check, and those without practice qualifications must practice under the guidance of practicing doctors.

The second is system construction, and continue to improve the system.

While implementing various medical rules and regulations and operating norms, the hospital revised the management norms of medicine, medicine and technology and the norms of clinical specialist diagnosis and treatment.

Third, regular medical quality inspection, continuous improvement of medical quality: the medical department conducts quality inspection on all clinical departments in the hospital. In strict accordance with the requirements of the Basic Specification for Medical Record Writing, organize medical record quality supervision and inspection at least once a month.

Fourth, the main defects

1, medical quality:

(1) The quality of medical documents in some departments is poor, which is mainly manifested in the same records of superior doctors' rounds, imperfect routine examinations, and many logical errors in medical records (such as patient's name, gender, age, inconsistent diagnosis inside and outside the hospital, etc. ), the important abnormal examination results were not analyzed and recorded, the diagnosis basis was insufficient, and some places where doctors or nurses should sign were not signed.

The daily course record is not written in time, and the job safety inspection and job risk assessment are incomplete.

(2) The use of antibiotics in some departments is not standardized.

(3) The work of medical quality control group in some departments has not been implemented.

Five, the next stage of medical quality and medical safety management focus:

1, strengthen the study of laws and regulations, strengthen supervision, strictly control the access to practice, and let medical personnel at all levels consciously practice medicine according to law.

2, strengthen the study of various quality management systems, improve the quality of medical care, so that the diagnosis is standard and the treatment is based.

3. Do a good job in the training of Basic Specification for Medical Record Writing (version 20xx) to improve the quality of medical record writing. Strengthen the "three basics and three strictness", continuously improve the professional quality and professional level of medical staff, and continuously improve the quality of medical services.

4, improve and unify the hospital medical quality evaluation standard.

5. Further improve the management organization at the hospital and department levels, and implement the medical quality management system and responsibility at the hospital and department levels.

6, now running medical records organized by the medical department for regular inspection; The medical department and the medical record room should organize the directors of relevant departments or quality control doctors to supervise and inspect the medical records regularly or irregularly, at least once a month.

Medical quality and safety work summary 4 pages

The ultimate goal of medical and health reform is to provide better medical services for patients at lower cost. In recent years, our hospital, like other municipal general hospitals, has become a basic part of medical and health work in our city, forming a unique maternal and child medical and health work system, and has made unremitting efforts in providing high-quality and low-cost medical and health care services for women and children in the region, inheriting and developing medical academics, and cultivating medical talents. In the past 20xx years, our hospital has adhered to the patient-centered service concept, based on improving medical quality, charging reasonably and reducing medical expenses, and strived to provide quality medical services for the majority of patients.

First, strengthen medical quality management to ensure and improve the quality of medical services.

(1) Medical quality management is the core of hospital management, and improving medical quality is the fundamental purpose of hospital management. Medical quality is the lifeline of the hospital. The level and quality of medical care are directly related to the survival and development of hospitals. In recent years, on the basis of high-quality medical service, our hospital has made it a top priority to reduce medical quality defects, timely investigate and eliminate medical safety hazards, reduce medical disputes and put an end to medical accidents. Our hospital strictly controls the quality of medical care, and all departments strictly implement various rules and regulations, standardize diagnosis and treatment behavior, and adhere to the system of first diagnosis responsibility system, three-level rounds system, consultation for difficult patients, consultation for critically ill patients, and discussion before and after operation. Strengthen the sense of responsibility, pay attention to the dynamic analysis in medical activities, and take various preventive measures to nip in the bud. In view of patients' increasing demand for medical information, various information systems should be improved.

Strengthen quality control management.

(two) optimize the medical service process, improve the quality of medical care. Service process is the operation structure and mode of medical institutions. On the basis of not increasing the number of wards and health technicians, the optimized medical service process determines the efficiency and competitiveness of medical institutions, which greatly enhances the long-term viability of hospitals. By balancing all components in the process, the duplication and waste of available resources are reduced, so that the existing hardware and software of hospitals can achieve higher utilization rate and better utilization level, and the ability of professional technicians can be fully exerted to meet the needs of patients as much as possible and reach a higher level. Our hospital insists on taking patients as the center, makes great efforts to optimize medical procedures, facilitate patients to seek medical treatment, seek practical results, enhance service awareness, optimize development environment, and strive to provide warm, convenient and high-quality medical services for patients. Various convenience measures have been introduced, such as networking toll registration windows, reducing long queues for registration, setting up special registration windows for some experts, and introducing telephone appointment registration. The medical technology department issued a report to launch a time-limited commitment. A group of advanced nurses emerged in the nursing department to carry out star-rated nurse selection activities. They set up a bridge between nurses and patients, introduced convenience measures and tried their best to solve practical problems for patients. The satisfaction of inpatients with nursing work reached 98%.

(C) the implementation of medical quality and medical safety education is the basis for strengthening medical quality. How to improve the quality of managers and strengthen the quality education of medical staff in the whole hospital is the basis of quality management. Improving medical quality can not be achieved by the efforts of several managers or a medical staff, but by the positive attitude of all hospital staff.

Correct outlook on life, values and professional ethics; Need a strong sense of responsibility, dedication and compassion; It is necessary to establish a firm awareness of medical quality and medical safety; Carrying out high-quality service and the activity of "safety is the greatest saving and accidents are the greatest waste" in hospitals has stimulated the professionalism of employees in learning and formed a good atmosphere for learning and catching up.

(D) Establish and improve the quality management system, and standardize medical behavior is the core. In recent years, our hospital has established five management systems, including post responsibility, medical ethics, personnel management, meeting, study, attendance, safety, logistics management, financial property management, statistical report management, medical document file management and rewards and punishments, with 24 items1. Twenty-six quality control assessment rules were formulated, including administrative management, medical quality management, nursing quality management, drug management, hospital infection control management, financial management, ideological and political work, and medical ethics management. Formulate comprehensive target responsibility letters for functional departments and business departments to realize the pattern of first-level management and first-level responsibility. Clear responsibilities, ensure functions, clear powers and responsibilities, moderate benefits, so that management can be followed by rules, and gradually improve the legalization, institutionalization, standardization and standardization of management.

Establish a quality management system in line with the actual situation of the hospital. The hospital has set up a leading group for quality management and quality control assessment with the president, vice president, medical department and clinical department as members, responsible for the quality management of the whole hospital. The whole hospital formed the main leaders to personally grasp; In charge of leadership; Functional departments grasp every day; Clinical departments have been paying attention to medical quality and medical safety management mode.

Strengthen medical quality management, adhere to the combination of routine inspection and monthly, quarterly and annual quality control, strictly control the quality of links and ensure the final quality. "Grasp the three basics" and "promote the three strictness", and implement the "three-level doctor" rounds system. The Medical Department often organizes hospital staff to learn health laws, regulations, systems, operating procedures and routines, and records them in personal business files. In recent years, by carrying out all-round quality management with medical business management as the goal, and striving to improve medical quality and ensure medical safety, all the work of the hospital has reached the expected goal of the comprehensive target responsibility system. The medical quality has been gradually improved, the potential safety hazards have been gradually reduced, no medical accidents have occurred, and medical disputes are relatively few, which has improved the medical quality and ensured medical safety, and prepared for the re-evaluation of the second-class first-class maternal and child health hospital next year.

Second, improving medical quality and reducing medical expenses are the most fundamental goals of hospitals.

Improving the quality of medical care, reducing medical expenses and allowing ordinary people to enjoy better medical services with less money are the most fundamental goals of medical system reform. Reducing medical expenses and improving economic benefits are also social issues that every dean, patient, social person, medical staff and so on are concerned about. It is a direct embodiment of social nature and service purpose. As a hospital administrator, we should strengthen scientific management quality, reduce management cost, improve service quality and professional quality, and emphasize "skill" rather than "cost" to win.

(1) This year, our hospital strictly implemented the procurement of drugs and large medical equipment.

Standard policy and drug "pricing" policy, implement separate accounting, manage and adjust the price of medical services, reduce the total medical expenses, and reduce the proportion of drug income in the total hospital income. It does reduce the financial burden of patients. To achieve the goal of "reducing patients' expenses", we must first solve the problems of ideological understanding and medical ethics, adhere to the purpose of "serving the people", correctly handle the relationship between social benefits and economic benefits, put social benefits first, and prevent the tendency of unilaterally pursuing economic benefits and ignoring social benefits. "patient-centered", taking patients' interests as the premise, taking medical treatment as the lofty profession, and handling the interests of hospitals, individuals and patients well; Effective examination and rational drug use, low price and high quality service, practice Theory of Three Represents in medical work.

Chapter IV: Summary of Medical Quality and Safety Management Over the past year, under the direct and correct leadership of the Health Bureau, our hospital has earnestly studied the relevant spirit of the Ministry of Health and our bureau on the reform of the medical and health system, devoted itself to the reform of the medical and health system, explored the medical market, and actively participated in market competition. Adhere to the patient-centered, all services for patients, constantly improve the quality of medical services, improve service attitude. Strictly grasp all kinds of medical quality control indicators, improve the overall level of medical care, effectively reduce medical disputes and put an end to medical accidents.