Annual summary of operating room quality control: XX is a year of "working hard and creating a leap". The hospital spent a year focusing on discipline construction and personnel training. Under the leadership and support of hospital leaders, the nursing department attaches importance to the cultivation of nursing backbones, optimizes nursing teams, improves the quality of nursing services, and strengthens supervision and management to ensure nursing safety. At the same time, the legal concept of nursing staff has been improved, and the monitoring of nursing quality has been strengthened, so that the quality of nursing service in the whole hospital has been steadily improved and the satisfaction of patients has been achieved. The work of the nursing department is summarized as follows:
First, pay attention to personnel training and optimize the nursing team.
1, strengthen nursing management training. This year, the hospital sent two head nurses to the Fourth Military Medical University for further study. At the same time, some standing Committee members of the hospital also trained the acting head nurses and the old head nurses in the hospital.
2. Optimize the whole nursing team and improve the comprehensive quality of nursing staff. The hospital sent 58 nursing backbones (including head nurse 10) to Tianjin Hospital, Beijing Hospital and PLA General Hospital in four batches for further study, which is the largest number of nursing staff going out for further study in recent ten years. It is particularly worth mentioning that in May, June, July and August this year, we completed heart surgery and postoperative care 14 cases with experts from general hospitals, and all patients recovered and were discharged.
3. Actively complete various trainings. The nursing department organized the nursing staff of the whole hospital to attend the special lecture 14 times, with the number of participants 1389. Clinical departments organize nursing rounds every month 1 time, and give special lectures for 4 class hours, encouraging nursing staff to publish scientific research papers. Continue to implement multi-channel academic training. By the end of this year, all clinical nurses in the whole hospital 193 have college degrees, including 5 with bachelor degrees and 27 under study.
4. Fully cultivate the organizational participation of nursing staff. "5。 12 "Nurses' Day held a number of activities with the theme of advocating humanized service, focusing on the performance of nurses' etiquette and the display of nursing operation techniques. Nurses do their best to strengthen nursing knowledge, cultivate sentiment and enhance the sense of collectivism honor.
5. Strengthen the teaching of interns. After the interns came to the hospital, they organized two pre-job trainings, mainly from the internship system and 50 basic operational skills. Every intern has a fixed teaching, a small teacher gives regular lectures on the specialties of the department, and the head nurse conducts theoretical and operational examinations. The department checks the interns layer by layer to ensure that no medical mistakes occur.
Second, strengthen supervision and management to ensure nursing safety.
1. The nursing department regularly supervises and inspects the nursing work, focusing on strengthening the pre-holiday safety inspection, enhancing the awareness of nursing staff to prevent accidents, standardizing the management of toxic and hemp drugs, realizing the management of special personnel at the counter and realizing the "four settings" of rescue drugs in the car: special personnel management, fixed-point placement, quantitative determination and shift change records. Rescue equipment should be repaired and maintained in time, and the functional status should be guaranteed for standby.
2. Insist on nurses' long-night rounds, supervise and inspect nurses' on-the-job and post responsibilities, find out the deviations in nursing work in time, correct them in time, insist on joint rounds of head nurses once a month, and hold a regular meeting of head nurses every two weeks, and formulate targeted and effective improvement measures to ensure the quality and safety of nursing.
3, in-depth departments to urge the head nurse to arrange daily work. Focus on the patients who are newly recruited, transferred to hospital, before and after operation, critically ill, unable to take care of themselves and have the potential danger of medical disputes, supervise and inspect the implementation of nursing work, strengthen link quality control, and reduce the occurrence of nursing defects.
4. Organize trainee nurses to carry out pre-job training. Through training, they have established legal awareness, quality awareness and safety awareness, conscientiously observed various rules and regulations and operating procedures in their posts, and fulfilled the sacred duties of the angels of white medicine. Better contribute to hospital construction.
Thirdly, standardize the writing of nursing documents and strengthen the consciousness of nursing legal system.
With the improvement of people's legal awareness and the promulgation of the new Regulations on Handling Medical Accidents, how to strengthen the legal system construction in nursing service and improve the legal awareness of nursing staff has become an important link in nursing management. This year, the nursing department formulated the Detailed Rules for the Writing of Nursing Documents in Hospitals in strict accordance with the requirements of the XX Military Region, and conducted training in the form of centralized teaching and study in different wards, which made nurses more clear about the significance of writing nursing documents, standardized nurses' behavior and improved nursing quality. When organizing lectures, we summarized and analyzed the actual situation of nursing document writing in our hospital, and put forward corresponding countermeasures.
Fourth, strengthen quality management monitoring.
1, the nursing department timely revised and improved the quality control standards of various nursing documents according to the writing norms of nursing documents, and the head nurse was responsible for checking the nursing documents.
2. The management of washing, disinfection and storage, receiving and dispatching of sterile articles in the disinfection supply room has been strengthened, ensuring the quality of sterilized articles and medical safety.
3. Strengthen the management of hospital infection control, organize head nurses and hospital nurses to learn new disinfection technical specifications and hospital infection management specifications, check and evaluate the implementation of disinfection for nurses through monthly quality inspection and nurses' overnight rounds, and focus on strengthening the monitoring and management of disposable sterile items, aseptic technology, sanitary hand washing, environmental sanitation and disinfection.
Fifth, improve the service quality and shape the image of the hospital.
Nurses are the earliest and closest workers who contact patients. The quality and image of nursing staff directly affect the image of the hospital.
1, starting with professional quality, the nursing department insists on conducting an operation and theory examination every six months, and the department organizes a business study and an operation technical training assessment every month, requiring everyone to pass the examination and cultivate a set of nursing staff with excellent business skills.
2, standardize the nursing staff dress, civilized language, answering the phone standard, let the nursing staff put into work with the image of end-loading, kindness, kindness and generosity and full mental outlook, and warmly receive patients with civilized and polite language.
Annual Summary of Operating Room Quality Control II: In 20XX, with the strong support of hospital leaders, nursing departments and relevant departments and the joint efforts of operating room personnel, the nursing quality management work was summarized as follows:
First, improve the service attitude, and earnestly achieve patient-centered humanized service.
1, the establishment of clinical communication mechanism, preoperative visit, postoperative follow-up and health education, recorded. The preoperative visit rate reached 90%.
2. Strengthen the patient's warm-keeping measures to prevent hypothermia during operation. Make a shoulder quilt, etc.
3. Protect the patient's privacy and put clothes and pants on the patient after operation. Painless catheterization in operating room can protect privacy, relieve pain, improve the success rate of catheterization and reduce urinary tract infection.
Second, continue to pay attention to the quality of nursing and ensure the safety of nursing.
1. Conduct business study every month, with each nurse giving lectures in turn and training at different levels. Conduct a "three basics" theoretical assessment every six months to strengthen the consolidation of professional knowledge.
2, according to the level of nursing operation every month to develop training and assessment plan.
3. Improve the nursing quality control organization and nursing quality group. Every month, each quality control team checks the nursing quality, perioperative period, identification, safe medication, catheter, pressure sore, fall, blood transfusion management, etc. And report the existing problems, analyze the reasons, make rectification, and let everyone in the department know. And the working quality is improved.
4, seriously implement the core system, do a good job in the safety verification of surgical patients, no medical accidents occurred throughout the year.
Third, strengthen the reporting of nursing adverse events.
1. Organize general nurses to understand nursing adverse events.
2. Make statistics and analysis on general adverse events every quarter, and report at the meeting to learn lessons and improve the work.
3. Encourage nursing staff in departments to actively report adverse events, and severely criticize and impose financial penalties on individuals who delay or conceal.
4.* * * Two adverse events were reported throughout the year.
Four, hospital infection management
1. Replace the disinfection machine in the operating room, and stipulate that it should be disinfected at least three times a day, and the continuous operation disinfection time must be more than half an hour.
2. Adjust the infusion time of antibiotics to ensure that it is completed half an hour before the operation.
3. Strengthen the training of hospital control knowledge awareness of cleaners. The staff on duty will evaluate, supervise and improve the work effect of the cleaning staff every day.
4, regular training hospital knowledge, learn the relevant rules and regulations. Operating room staff abide by rules and regulations and labor discipline.
Problems in quality control inspection of verbs (abbreviation of verb);
1, disinfection and isolation management:
Sterile items and non-sterile items are put in the same cabinet.
The opened saline was not marked with date, time, name and signature.
Disposable goods has not been classified and treated after use.
2, safe medication management:
The medicine was scattered outside the box, not in the original bag.
The doctor's advice was not signed in time after execution.
The patient's name and department bed number are not marked on the intravenous infusion bottle.
3, nursing safety management:
The fall prevention bed protection of surgical patients is not in place.
The items used in the operating room are not located.
After the glass ampoule is not standardized, the protection is not in place.
4, rescue vehicle management:
The oxygen pillow is not in standby state.
5. Intravenous infusion and pressure sore management:
After catheterization, the nurse did not sign the full name and the record was incomplete.
Pre-operative pressure sore evaluation and reporting procedures for high-risk patients are not standardized.
In view of the above problems, our department has taken rectification measures, strengthened the management of first-aid articles, paid attention to detail management, made the intact rate of first-aid articles reach 100%, strengthened the management of hospital infection, and prevented cross-infection in the hospital. Strengthen the weak links in nursing safety management (such as equipment management) to make them have preventive measures and emergency plans, and put them into practice.