《2018年医疗质量检查考核表.pdf》由会员分享，可在线阅读，更多相关《2018年医疗质量检查考核表.pdf（8页珍藏版）》请在taowenge.com淘文阁网|工程机械CAD图纸|机械工程制图|CAD装配图下载|SolidWorks_CaTia_CAD_UG_PROE_设计图分享下载上搜索。
1、淮南泽明眼科医院 2018 年医疗质量检查考核表 科室:检查人：督查项目 分值 考核评分标准 扣 分 原 因 得分 一 依法 执业 4 1.医师、护士必须依法 执业；2.医护人员配备及资 质满足工作需要；3.手术及有创操作应 按照有创技术操作的 卫生技术人员的授权 开展工作。医护人员配备及资质不能满足工作需要 或未经授权开展有创 技术操作的均扣 2 分。二 科室管理 18 1 制度健全 4 1.各项医疗质量和医 疗安全核心制度健全；2.有与本科室工作特 征相符合的各类人员 的工作职责、疾病诊断 治疗规范、专科医疗护 理工作流程、风险管理 应急预案、医院感染控 制常规等。3.医护人员知晓各项 制
2、度、本岗位职责与应 急预案。一项不符合扣 0.5-2 分。2 质控小组 5 1.成立科室质控小组，制定年 度工作计划和 明确的质量与安全管 理指标；2.科主任是质控小组负责人，小组内分工合理，有专职或兼职人员 负责院感工作；3.每月开展质控活动 并有记录，至少每季度 对质量问题进行分析 和持续改进。一项不符合扣 1 2 分 3 科室管理记录 3 科室建立交班本、疑难 病例讨论本、危重病例讨论本、危急值登记本、医 疗安全（不良）事件登 记本等，各项记录及时、规范、准确。一项不符合扣 0.5 分 4.仪器、设备、物品 管理 6 1.诊疗、抢救用仪器、设备、药物等处于完好 备用状态；2.抢救用面 罩
3、、复苏气囊、气管插管等管理有缺陷或抢救用 物不适用，此项不得分。三 落 实 医 疗 质量 管理制 度，重点是核 心制度 45 抽查 4 份病历（手术 病历 3份，非手术病历 1 份抽查病历病案号为。1 落实 首诊负责 制度 5 1.首诊医生不推诿患，特别是对急、危重 患者的检查、诊断、治疗、等工作 负责到底；文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z
4、1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:
5、CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z
6、1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:
7、CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z
8、1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:
9、CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W62.首诊医生完成检诊和病历书写，会诊前完成必要的处
10、 理；3.危急患者先抢救再办有关手续；4.首诊病例转诊符合程序规定和制度。一项不符合扣 0.5 分 2 落实三级 医师 查房 制度 5 1.各级医师按规定查 房；2.查房内容符合要求；3.保护患者隐私和知情同意权；4.三级查房病程记录符合要求。一项未做到扣 1 分 3.会诊制度 落实 3 1.会诊医师资质、会诊 时限符合要求；2.会诊单、会诊记录 完整、规范。上述一项不符合扣 1 分 4 值班及交接班 制度 落实 5 1.值班医师有资质及 配班符合要求，一线 班、二线班、住院总在 规定时间内查实在岗；2.科室有交接班登记 本，并规范执行交接班 制度；3.危、重、新入 院、手术患者有记录、有交接
11、班；4.抽查值班 医师对在院患者特别 是对重点患者 文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2
12、V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4
13、W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2
14、V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4
15、W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2
16、V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4
17、W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6病情掌 握。值班医师资质不 符合扣 2 分；交接班本 记录不连续，每缺 1 次 记录扣 1 分；当日交接 班的记录不全，缺交接 重点扣 1 分；值班医师 对重点患者情况未掌 握扣 1 分；交接班本未 记录（交班）危急值处 理情况的扣 1 分。5 疑 难、危重 病例 讨论制 度 3 1.有疑难、危重病例讨 论
18、制度，按照规范要求 进行疑难病例讨论；2.讨论由科主任或具 有高级职称的医师主 持；3.在科室疑难病例讨 论本上规范记录；一项不符合扣 1 分。6 术前讨论制度 3 1.有术前讨论制度并 执行；2.讨论人员、程序、内 容规范，记录齐全。一项不符合扣 1 分 7 查对制度 4 1.患者按规定佩戴腕 带；2.医护人员在任何涉及患者干预的情况下 均使用两种及以上方 法（姓名、性别、年龄、出生年月、病历号等）识别患儿身份；一项不符合扣 1 分 文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6
19、文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8
20、J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6
21、文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8
22、J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6
23、文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8
24、J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6
25、文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W68 手术安全核查 8 1.有手术安全核查制 度；2.有术前核查和手术/手术操作部位标识的 相应流程并落实。现场查看手术病人 2 例，一人未做到扣 1 分，科室无该制度扣 3 分 9 手术分级 管理 制度 5 1.各级医生按照手术分级管理制度进行手 术申请、审批、操作；2.超范围手术要申报 审批。一项不符合扣 1 分 10 新技术和新项 目准 入制度 2 1.执行新技术和新项 目准入制度；2.新技术开展申请规 范，有可行性论证和安 全保障措施，通过伦理 委员会批准。一项不符合扣 1 分 11 抗菌药物分级 管理 制度
26、 3 1.有抗菌药物分级管 理制度，有对抗菌药物 临床应用知识和规范 化管理的培训与考核；2.临床应用非限制使 用、限制使用与特殊使 用抗生素符合规范；3.将抗菌药物合理使用 纳入科室质控小组质 控内容。一项不符合扣 1 分 四 医疗安全风险 15 文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W
27、6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V
28、5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W
29、6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V
30、5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W
31、6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V
32、5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6管理 1 制 度、预案 3 1.有医疗安全与风险 防范相关工作制度、应急预案（包括风险识 别、评估、分析、处理
33、和监控等内容），医护人员熟知制度及预案；2.具有预防患者意外伤害的设施：病床有护 栏且规范使用，病床传呼系统能正常使用，开 水炉防止烫伤的防护 设施有效，病区有防 滑、防跌倒宣教等。一项未做到扣 0.5 1 分 2 临 床“危 急 值”管理 6 1.建立“危急值”报告 制度及流程，确定“危 急值”项目；2.建立危急值登记本，规范、准确记录患者识别信息、检查（验）结果和报告 者的信息；3.病历中有 医师及时追踪处置的记录；一项不符合规 范扣 2 分。3 医 疗 安 全（不 良）事件 管理 6 1.有不良事件上报管理制度与工作流程，有建立医务人员主动报 告不良事件的激励机 制，医护人员熟知该内 容
34、；2.每百张实际开放床 位年报告医疗安全（不 良）事件10 件，文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1
35、 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8
36、H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1
37、 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8
38、H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1
39、 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8
40、H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6有定 期分析改进；3.重大医疗安全事件 无瞒报、漏报，对重大 不安全事件进行根因 分析（非预期的死亡、非计划二次手术、二次 入院、严重并发症、医 疗事故、纠纷等）。一项不符合规范扣 2 分。五 医 院 感 染 管理 10 医务人员在临床诊疗操作过程中必须严格执行无菌操作及手卫生管理制度（手清洁、
41、手消毒、外科洗手操作规程）发现一名医务人员没有严格执行无菌操作或手卫生管理制度扣 2.5 分，造成严重后果扣完患者安全大项 15 分。六.临床路径 3 1.临床路径培训；2.临床路径70%；没开展临床路径 0 分；50%入径率为 1 分；50%70%入径率为2 分 七 双向转诊安全 5 1.有本科分级诊疗双 向转诊制度、流程、眼科疾病分级诊疗指 南；2.有上、下级医院签订 转诊协议；3.对转入、转出的患者 进行转诊登记。一项不符合扣 1-2 分 文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V
42、5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W
43、6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V
44、5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W
45、6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V
46、5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W
47、6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V
48、5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6 文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4
49、W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2
50、V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4W6 HL8J7R4Z1M1 ZN5E2V5H4W6文档编码:CK8H1Q9V4