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2018年医疗质量检查考核表.pdf

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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

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关键词：: 2018 医疗质量检查考核

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