Hospital department self-examination report (general 5 articles)
Time flies, and a period of work has ended. Looking back on the work during this period, there are many problems, and the achievements and shortcomings Put it together into a self-examination report. In order to save you the headache of writing a self-examination report, the following is a self-examination report for hospital departments that I compiled (5 general articles). I hope it can help everyone.
Hospital department self-examination report 1
With the attention of the hospital’s leadership, the entire hospital has conducted a comprehensive self-examination and self-correction in response to the current bad medical behaviors in some medical units. Job inspection. The Laboratory Department has conducted comprehensive self-examination and self-correction inspections on management, quality, safety, services, etc. within the department. After three days of self-examination and self-correction, and comparing with relevant medical regulations and systems, we discovered some hidden dangers and formulated relevant measures. A brief summary is as follows:
1. The quality of specimens is that most specimens are qualified, and unqualified specimens have rejection records and re-sampling. Existing problems: Insufficient communication with the nursing department and nurses in each district requires a more comprehensive and timely reflection of quality problems existing in blood drawing. Measures: Report relevant specimen quality to the Nursing Department in a form on a quarterly basis to promote quality improvement before inspection.
2. Indoor quality control must be carried out every day for all indoor quality control projects, with records, analysis and treatment of out-of-control points. Good quality control.
3. Laboratory quality control can participate in the laboratory quality of various projects of Foshan City, Guangdong Province and the Ministry of Health on an annual basis. There are records and feedback analysis, and strict control by the quality director. Similar analytical instruments have regular comparisons of measurement values. The data shows that the measurement results between different analytical instruments are within a reasonable acceptable range.
4. The critical value reporting system can be carefully implemented by each laboratory and recorded and processed. There was a problem, and one case of false critical value was found to be improperly handled. Measures: Strengthen the learning and training of staff's professional abilities and continuously improve their own professional abilities. Standardize and implement the handling and reporting of critical values. Everyone is required to pass the test.
5. Inspect dangerous goods, safe electricity use, and fire hazards. Dangerous goods are managed under lock and key and registered for use. No potential safety hazards in the use of electricity or electrical appliances were found. No potential fire hazards were identified. Fire-fighting equipment is qualified and stored as required.
6. The service capability is able to issue reports on time, and the timely rate of inspection reports reaches 95%. Service satisfaction reaches 90%. The score is 84 points. Service level and quality still need to be continuously improved. Strengthen ideological and professional ethics education, establish new trends in the industry, and create civilized service windows.
This self-examination and self-correction inspection will greatly promote the improvement of the quality of inspections in our department, and have positive significance in ensuring medical safety and eliminating hidden medical risks. Hospital department self-examination report 2
xxx Hospital conscientiously implements the spirit of the District Health Bureau’s safety work meeting, includes production safety and fire safety work on the agenda of daily work, and formulates and implements various management systems, Propaganda education system. Adhere to the principle of giving priority to prevention, combining prevention and treatment, assigning responsibilities to people and implementing them in place. The specific self-examination results are reported as follows:
1. Safety production responsibility
1. No major medical safety accidents occurred in 20xx.
2. Basically improve various medical management systems, strictly implement various operating procedures, and no medical errors or medical accidents have occurred; no occupational exposure incidents have occurred.
3. The focus of medical errors is prevention. A quality and safety control management committee has been established in the hospital, and a quality control team has been established in the department to identify the person primarily responsible for medical safety and form a "one post, two responsibilities" mechanism. Everyone signs Safety responsibility letter, and hold regular medical quality and safety control meetings to ensure that medical errors and accidents do not occur.
4. Regularly carry out quality control self-examination work, and conduct rectifications of hidden dangers of medical accidents within a time limit; regularly conduct medical technical knowledge training to improve the professional capabilities of all medical staff and effectively prevent the occurrence of medical errors and accidents.
5. Strictly implement the medical personnel access system, and only those who have obtained the health technology qualification certificate can work and practice.
2. Fire safety responsibility work
1. Establish a sound organization and clarify work responsibilities
Fire safety is an important part of our hospital’s work and is related to employees The safety of patients’ lives and the safety of hospital property are top priorities. In response, in 20xx, our hospital established a fire safety working group with the executive dean as the team leader, the safety officer as the first person in charge, and the directors of each department as the direct responsible person, to be fully responsible for daily fire safety work.
2. Strengthen publicity and education and enhance fire safety awareness
Our hospital attaches great importance to fire safety work, continuously strengthens fire safety knowledge training for all employees, and communicates through centralized learning and decentralized learning. In a combined way, we actively learn fire safety related knowledge, effectively improve the fire safety awareness of all employees, establish the concept of "everyone is a firefighter, and everyone is responsible for fire protection", and ensure that every employee can use it skillfully. Fire-fighting equipment and common sense of first-time fire fighting and escape and self-rescue are required to effectively implement fire safety work into daily management.
3. Carry out fire safety self-examinations carefully to identify and eliminate fire hazards
The hospital system stipulates that the logistics department will inspect fire hydrants, fire extinguishers, and safety passage signs in the corridors of the entire hospital every week. A comprehensive self-inspection of electrical and gas facilities such as power lines, liquefied gas tanks, water dispensers, computers, printers, sockets and hubs was conducted. Over the past year, no signs of aging, exposure, burnt, flammable and explosive items, or power consumption were found in the power lines. Equipment overload operation and other phenomena.
In short, for hospitals, medical safety and fire safety are top priorities. We will implement the policy of "safety first, prevention first, comprehensive management", strengthen supervision and inspection and strengthen daily Management work, improve the safety responsibility awareness of all employees, effectively prevent problems before they occur, and create a safe and harmonious working and medical environment for hospital employees, children and parents. Hospital department self-examination report 3
The county has gradually implemented standardized management of township health centers. By holding mobilization meetings, issuing implementation plans, clarifying work goals and tasks, and formulating work measures, we will first use pilot projects in some township health centers as a guide and gradually roll them out throughout the county. So far, this work has been fully implemented in 13 township health centers across the county. According to the requirements of superiors, the progress of the standardized management pilot work of township health centers in our county is now self-examined and reported as follows:
1. Work achievements
1. Through the inspection of all aspects of medical care in health centers The standardized construction of clinical departments and public health vaccination clinics and environmental construction have further improved the infrastructure construction of township health centers including department configuration, medical equipment equipment and use, and appointment of professional and technical personnel.
2. Through the unified management of people, talents, and materials in township health centers, the health centers are responsible for the deployment of technical talents, qualification access, funding, asset management, and business of the unit and village clinics within its jurisdiction. Guidance and work coordination, public health, medical market supervision, etc. have streamlined the management system of township health centers.
3. Completed the reform of the personnel allocation system of township health centers. On the basis of implementing the target responsibility system for the director’s tenure and improving various management systems, the department settings of township health centers were divided into public health departments. and medical care. It is clarified that each township health center mainly provides public health services. On this premise, the central health center must further improve the level of medical technology and guide the business work of surrounding general health centers. A strict performance appraisal system has been established, and the distribution of personnel wages is linked to the services provided and labor contributions, which has improved the intrinsic vitality of township health centers and stimulated the enthusiasm of the majority of cadres and employees.
4. Institutionalized management has been implemented in both the administrative and business aspects of the health center. Class-oriented goals and tasks for hospital leaders and department heads were set. Implement a job responsibility system that combines responsibilities, rights, and interests, and establish and improve various medical care work systems including handover of clinical departments, standardized writing of medical documents, error and accident registration, disinfection and isolation, etc., to prevent medical disputes and eliminate medical liability accidents occurrence.
5. Actively carry out counterpart support work for rural health institutions, arranging for 5 county-level medical and health institutions to provide counterpart support to 13 township health centers, and arranging 13 township health centers to be divided according to their regions, responsible for 248 of the county's The village clinic's coverage responsibility system has effectively established and improved the infrastructure of the rural three-level medical care network and maximized its due role. By signing a counterpart support agreement, the work goals, tasks, working methods, time, and responsibilities and powers of both parties are clarified, which improves the management and service capabilities of grassroots medical and health institutions at all levels, thereby enabling the assisted township health centers and villages to The clinic has undergone significant changes and rectifications in terms of environmental construction and connotation construction.
6. Strengthened the management of full-time personnel such as township health center accountants, defense specialists, maternal and child specialists, and joint treatment specialists, and formulated employment and assessment management methods for each specialist. Recruitment must be reported by the health center and hired after approval by the health bureau. The health center cannot change at will without permission from the superior authority. This ensures the stability of the full-time staff of the health center and effectively promotes financial, public health and other aspects of employment. the smooth progress of the work.
7. The "Ten Standards for Directors of Township Health Centers in Huaxian County" were formulated and issued to strengthen the management of health center directors. It is clearly required that the directors of health centers carry out various tasks in accordance with relevant national laws and regulations, obey the management of the health bureau, ensure the smooth flow of government orders, strictly observe self-discipline in accordance with the requirements of the "Ten Standards for Directors of Township Health Centers in Huaxian County", and complete various tasks on schedule.
2. Existing problems
1. Due to historical reasons, some township health centers are short of technical personnel and small in scale, and the existing medical equipment cannot play its due role. Solution: The health center is solving the problem through temporary secondment, entrusted training, etc.
2. Unbalanced distribution of medical equipment resources. Solution: Through investigation and statistics, the Health Bureau will uniformly register, repair, maintain and debug all damaged and idle medical equipment in township health centers across the county, and then redeploy them for use. In order to improve the utilization rate of equipment and facilitate the people to seek medical treatment.
3. Effectively combine the inherent common points in the standardized construction of village clinics, standardized management of township health centers and integrated management of rural health services, and jointly focus on management, scientific and reasonable Arrange deployment and greatly improve work efficiency.
In order to steadily implement the national essential drug system, effectively solve the problem of "difficulty and high cost of medical treatment" for the masses, and implement the people-benefiting policies of the party and the country, we have strengthened measures, paid close attention to implementation, and solidly promoted the "Three Drugs" Work in unison”.
We now report the self-examination of the “three unifications” work of drugs in our jurisdiction as follows:
1. Our hospital has established a leading group for the “three unifications” work, headed by the president. . We have formulated pharmacy quality management policies and objectives, compiled quality management program documents and operating procedures, and implemented a combination of regular inspections and routine inspections to ensure that our hospital's pharmaceutical quality management work is well-founded and has rules to follow.
2. Our hospital has been distributed by the "Three Unifications" enterprise since October 20xx, and the utilization rate of basic drugs is 100%.
3. There are 15 standardized village clinics in our area, all of which have signed contracts with the "Three Unifications", and the drugs are purchased by the "Three Unifications".
4. We have trained all staff in our hospital on the "Clinical Guidelines for Essential Drugs". Currently, clinicians can use essential drugs reasonably and safely.
Main problems existing in the "Three Unifications" distribution process:
1. The distribution company's drug varieties are not comprehensive, and some necessary drugs cannot meet the clinical needs of hospitals and village clinics. Such as first aid medicines.
2. The delivery of medicines is not timely during the distribution process.
3. Some medicines are relatively expensive.
In the future work, we are determined to implement the reform of the national essential drugs system, increase the intensity of publicity and supervision, improve the long-term supervision mechanism of the "three unifications" of drugs, and ensure the smooth work of the "three unifications" of drugs. Advance. Hospital Department Self-examination Report 4
In order to implement the Ministry of Health’s “Hospital Management Year Activity Plan” and implement the unified layout of the hospital, the Medical Technology Department carried out the “Hospital Management Year Activity Plan” through study and combined with the basic conditions of the undergraduate department. "Activity Plan" activity requirements clearly define the importance of strengthening the connotation construction and internal management of medical institutions, improving the quality of medical services, ensuring the health and life safety of the people, promoting the healthy development of medical and health undertakings, and implementing self-examination and self-correction through learning and comparison, Solve existing problems.
There are indeed medical safety hazards in the development of hospitals. The main reasons behind these problems are that the various systems of the department have not been fully implemented, safety awareness is weak, management and supervision work is lax, and connotation construction is ignored. In the context of the current medical and health system reform, it is necessary to effectively strengthen industry management, stabilize medical order, and ensure medical care. Safety is especially important. With the theme of "Patient-centered, Improving Medical Quality", we conduct a search and sorting out medical diagnostic technology and take targeted measures to eliminate various hidden dangers that disadvantage patients. Establish a long-term management mechanism. Thoroughly implement the core system and standardize various inspection operating procedures. Complete examination and writing reports carefully to provide effective diagnostic opinions for clinical examinations of patients.
Establish an orderly work process. When there are many patients for B-ultrasound and color ultrasound, the examination process is chaotic. Some patients wait for too long, family members have opinions and quarrels occur. In this regard, examination registration must be established Window, check in order of number, [except emergency room]. To prevent the rush to be the first to induce conflicts. The number of B-ultrasound examination patients has increased significantly. The current two units cannot meet the needs of the development of the situation. The number of units must be increased, equipped with computers to print reports, and the reporting form of the inspection sheet should be standardized. The inspection report results must be signed and reviewed by the examining physician before being issued. The shortage of B-ultrasound medical technicians should be resolved immediately. Solve the duty regulations, assign people to the positions, and implement a 24-hour on-duty system.
In the endoscopy room, most people are late for work, the anesthesiologists do not arrive on time, and patients often wait for too long. The inspection is carried out on a first-come, first-served basis. The gastroscopy room nurses must strictly disinfect the gastroscopy equipment and pay attention to the concentration and effective time of the disinfectant prepared to prevent nosocomial infection. In terms of the quality of medical diagnosis, the inspection must be careful and the work You must recognize it, your attitude must be attentive, and everything must be carried out in accordance with operating standards to avoid mistakes. Colonoscopy will be performed in the morning and afternoon, and colon cleaning and lavage will be done before the examination. Everything must be done for the sake of patients, to solve the problem of difficult and expensive medical treatment, and to achieve the lofty idea of ??sincerely serving patients.
The new equipment 16-slice spiral CT has been launched for more than half a year. Since its launch, it has been basically perfect to meet the needs of clinical examinations. However, it has not yet exerted the full inspection function of the 16-slice spiral CT, and has gradually expanded the scope of examination to Guangshen develops and develops new projects. Although a lot of achievements have been achieved, many problems still exist.
The system is not implemented in place and the operating procedures are not standardized enough. Especially in terms of abdominal examination, there are no standardized examination requirements for patients before examination, which affects the image quality and results in ambiguous diagnosis quality.
Diagnostic quality control is not strict, and misdiagnosis and misdiagnosis occur. In this aspect, we must increase efforts to control quality, implement a three-level film reading and review system, and put more effort into quality control.
Specify the time for taking the film and reporting the results. For emergency, the film will be collected within half an hour and the results will be obtained within one hour. For non-emergency examination, the head will be examined in the morning and the results will be obtained at 4 p.m., and the chest and abdominal examination will be obtained at 10 the next day. Click to get the results, and patients with abdominal examination will have to have a plain scan plus enhancement, and pay a one-time fee, reducing the patient's trouble of paying back and forth.
Accelerate the learning of business knowledge for new projects, take the examination of various parts of vascular imaging as the main research topics in future work, image three-dimensional reconstruction processing, and more importantly, accelerate the development of CT diagnostic technology, and participate in online exchanges through short-term training Learn and discuss, and gradually improve the level of professional and technical diagnosis.
The discussion of difficult cases is not standardized. There is no perfect system in place, doctors’ opinions are not recorded and corresponding data are archived, case tracking and feedback is lacking, and there is a lack of careful summary. In this regard, we must start to improve and establish a long-term mechanism, formulate effective measures and plans, focus on film reading, case discussion and analysis, report review and verification, case tracking record files, continuous summary, strive to learn new technologies, create new projects, and give full play to the 16 rows The function of spiral CT is to control the quality, speed up the learning of technical knowledge such as vascular imaging, endoscopy, and three-dimensional reconstruction, and improve the professional diagnostic technology level of CT imaging.
Poor labor discipline consciousness, late for work, failure to implement hospital rules and regulations, and absenteeism on duty, which sometimes leads to complaints from patients’ families. Currently, B-ultrasound, color ultrasound, and CT have implemented a 24-hour on-duty system. Solved the problem of checking emergency patients at any time.
By studying and implementing the hospital management year activity plan, we further understand that medical staff must think about patients in everything they do, solve the problem of difficult and expensive medical treatment, and achieve the noble goal of serving patients sincerely. Thought. Provide high-quality services to the majority of patients and work together to accelerate the bright future of the hospital's overall planning and development. Self-examination report of hospital departments 5
In order to conscientiously implement and implement the spirit of the instructions to strictly manage medical and health institutions in accordance with the law, improve the standardization and institutionalization level of hospital work, strengthen the connotation quality construction of the hospital and ensure medical safety, all departments have Self-examination and rectification will be carried out on this work, and the situation report is as follows:
1. Basic situation of medical quality and safety management
(1) Improve the safety management system, with clear responsibilities and assigned responsibilities to each person.
We have formulated medical quality and safety management plans and assessment standards, improved various medical management system responsibilities, and conducted regular inspections. Establish diagnosis and treatment procedures for specialist and professional diseases, especially invasive examinations and treatments (such as interventional diagnosis and treatment procedures), and carry out clinical work in strict accordance with the procedures and diagnosis and treatment guidelines to ensure medical quality and safety.
(2) Education on medical quality and medical safety has been strengthened, and the safety awareness of medical staff has been continuously improved.
Through various learning methods, we provide quality and safety education to department members and strengthen training and assessment of laws, regulations and rules and regulations.
(3) The plan to prevent medical accident disputes and accidental injuries caused by non-medical dispute factors has been improved, and a mechanism to prevent and handle medical disputes has been established.
(4) In terms of nurse management, nursing management work can be implemented strictly in accordance with the "Nursing Regulations" and the nursing staff should be organized to study the "Nursing Regulations" carefully to ensure that they know the law, abide by the law and practice in accordance with the law.
(5) According to the national "Measures for the Management of Hospital Infections" and based on the actual situation and task requirements of the hospital, training on hospital infection knowledge has been strengthened to improve medical staff's awareness of hospital infection control and disinfection and isolation.
2. Effectively strengthen nursing safety and quality education
(1) Establish a patient-centered service concept and vigorously advocate changing passive to proactive thinking.
(2) Clarify job responsibilities, summarize experience, establish a long-term mechanism for continuous improvement of nursing quality, and improve the level of nursing work.
(3) Strengthen the study and assessment of the "three basics" of nursing. Improve the professional skills and theoretical knowledge of nursing staff, and strengthen the learning of new business and new technologies.
(4) Strictly implement the medical order execution system and increase supervision and inspection.
(5) Strengthen the training of aseptic operating procedures and strengthen the management of sterile items.
(6) Implement various systems, strengthen doctor-patient communication, enhance doctor-patient understanding, and conscientiously implement the signing of various informed consent forms.
3. Existing shortcomings
(1) The implementation of various rules and regulations is somewhat inadequate.
(2) There are defects in the writing of medical records and nursing documents.
(3) The mechanism for preventing and handling medical disputes needs to be improved.
(4) Nursing management needs to be improved.
IV. Specific rectification measures
(1) Conscientiously implement laws and regulations, establish and improve various rules and regulations, conduct intensive training on core systems, and ensure that all systems are implemented in place. Strengthen medical quality management, implement medical quality assurance plans to assess the implementation and implementation of various rules and regulations and personnel position responsibility systems, ensure medical safety and service quality, and continuously improve service levels.
Implement the "Practicing Physician Law", "Nurses Management Measures", "Medical Accident Handling Regulations" and other regulations, with medical quality management as the core, focusing on the strict implementation of various medical systems, measures, and procedures, and focusing on the quality of medical records and the quality of basic medical care. and medical practice practices. And carry out the study of laws, regulations and rules and regulations, and repeatedly strengthen the legal awareness of medical staff. Morning meetings and daily business study time are used to give lectures on legal knowledge and medical dispute prevention cases, and safety analysis meetings are held regularly.
(2) Establish and improve relevant rules and regulations such as medical waste treatment management, nosocomial infection and disinfection management, and waste leakage treatment plans. Keep complete records of the source, type, quantity, etc. of medical waste, and conduct regular disinfection effect monitoring. Strengthen the supervision of nosocomial infections, conscientiously implement the "Hospital Infection Management Measures", establish a complete hospital infection management and management organizational system, strengthen the monitoring of hospital infection cases, disinfection and sterilization monitoring and hospital infection reporting systems, and continue to improve hospital infection control management.
(2) Strengthen rational clinical use of drugs, strictly implement laws and regulations such as the "Drug Administration Law", "Prescription Management Measures", "Guiding Principles for Clinical Application of Antimicrobial Drugs", strengthen prescription management, implement a prescription review system, and ensure reasonable use of drugs. Medication.
(3) Strengthen the supervision of medical records. Establish and improve the full-process quality monitoring, evaluation, and feedback system for cases, focus on strengthening real-time monitoring and management of running cases, and improve medical record writing standards. Conduct medical record writing training for medical staff with reference to the "Basic Standards for Writing Medical Records" and "Regulations on the Management of Medical Records in Medical Institutions", strengthen management, and write medical records in strict accordance with the standards.
(4) Establish a medical dispute prevention mechanism and handling mechanism, improve the reporting system, handle and properly resolve medical disputes in a timely manner, fail to rectify hidden dangers of accidents, delay the rectification of various special projects, and fail to report in a timely manner in accordance with regulations will be investigated responsibility. Implement the medical safety responsibility system. In accordance with the principle of "from top to bottom, grasping the first level, and from bottom to upper level to maintain the first level" in safety work, implementation is carried out at every level, down to the individual level. Actively report adverse nursing events and improve the quality management system for special care, such as various types of catheters falling off, patient falls, bedsores, etc. Be able to use the results of adverse event evaluations to improve the corresponding application mechanisms, work processes, and work systems.
(5) Strictly implement nursing management work, formulate and safe nursing work systems, position systems, nursing routines, operating procedures, etc. in accordance with the "Nursing Regulations" and ensure their implementation. Formulate and implement nurses' job responsibilities and work standards, and standardize clinical practice behaviors. Establish a nurse performance appraisal system, and combine the appraisal results with the nurse evaluation based on the quantity and quality of clinical nursing work completed by nurses and the satisfaction of inpatients. Establish a complete nursing management organizational system. Implement a target management responsibility system with clear responsibilities.
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