天津市北辰医院风险管理计划.doc

out city created, and care masses life, focus work, in-depth investigation, more out boutique masterpiece, makes we of research results more to into led of decision vision, more to in national some has effect of newspaper Shang published, for advance work, and publicity changde play due of role. Third, information submitted to be pragmatic. Quick and timely. The ancients said: for the time system; statement back for the time being, nothing. Therefore, the submission of information to do four, that is, find the problem faster, editorial writing, send and read faster approval and feedback to implement quickly. To be true and accurate. True mainly reflect the full picture of events, one is one, two, this is the life of the information. Accuracy is primarily qualitative and quantitative questions, quantitative objective of publicQualitative logic. To be reliable and useful. We submit information to have access to decision-making, to guide and promote the work and solve practical problems. Mixed cum. On the negative information and emergency information, rapid escalation in strict accordance with the procedures, firm, newspaper, newspapers, never late, fail to report, false claim and skimming. Investee 2. supervision and insist on, around and protecting their interests to touch the truth, seek practical results. Adhere to people-oriented, the most important thing is to realize, safeguard and develop the fundamental interests of the overwhelming majority of the people. We carry out inspection, so must go deep among the masses, go deep into the realities, always pay attention to the peoples livelihood, to grasp the public sentiment, and earnestly safeguard the benefit, addressing the masses are most concerned about and reflecting the strongest issues, efforts to solve the problem of decisions implemented and not implemented. One is to stick to principles. Right of inspection is one of the most important powers of the Office, should not only dare to use, but also with caution. So-called dared to use, is to hold a number of important issues, bold supervision over supervision, track inspection, problems are not solved do not pass, the blame does not hold did not miss, dissatisfaction of the masses did not miss, the real right of supervision authority, with the benefits. Call with caution, is supervising departments should strengthen the consciousness of authorized strictly according to procedure, preventing the supervision and excessive to prevent adding burden to grass-roots. To this end, the supervision Department of the Party Committee of supervision must be under city and County party Committee Secretary-General (Office). Second, we should focus on. Is the Governor, those related to the globalEvent, Governor the protracted difficult, strong Governor during emergency urgent. Not having special departments in charge of the General Governor, under the normal procedure can do good things not Governor, not authorized by County leaders, not the Governor. Third is to solve the problem. The purpose of supervision, to resolve the problem. To adhere to and further improve the天津市北辰医院心内科风险管理计划 澳新风险管理标准AS/NZS4360 是澳大利亚、新西兰两国联合制定的世界上第1 个国家风险管理标准，它的特点是把风险管理看作一个过程，并给出了这个过程的一般定义，即通过沟通与协商、建立风险管理环境、风险识别、风险分析、风险评价、风险处理、风险监控与回顾7 个程序，将风险避免或控制在可接受范围； 采用风险发生5 级概率（确定发生的、很可能的、可能的、不太可能的、极少的）和风险发生后5 级损害程度（最大的、较大的、中等的、较小的、微不足道的）进行风险的大小分析评价，并通过红、黄、绿色标识划分高、中、低风险和可否被接受的风险程度，把风险和企业的目标紧密结合起来1。近年来,国外将此标准应用于医疗风险控制取得了良好效果，应用到我国医院风险控制的实证不多。结合澳新风险管理标准（AS-NZS4360）以及HSMT9007A课程的学习，制定天津市北辰医院心内科风险管理计划。1.组织环境天津市北辰医院是一所二级甲等医院，是北辰区唯一一所综合性医院，心内科是医院重点科室。科室床位40张，其中CCU病床10张。医生12人，护理人员18人。科室主要承担心绞痛、急性心肌梗死、心功能不全、高血压、心律失常及先天性心脏病等疾病的诊治工作及心血管危重的救治。每年收治的心脏病患者约 3000余人次，CCU每年收治急性心肌梗死420余人，心力衰竭病人800余人次。心内科的患者有起病急骤、病情变化快、且患者年龄偏高等特点，在医疗安全上存在着风险因素。同时，由于人事体制问题，临床医护人员严重缺编，且年资较轻，加班工作导致体力疲乏，工作效率下降，发生重大差错和安全事故。在外部方面，主要是：医疗不良事件频发，已成为世界性的问题。各国为此付出巨额代价，中国医疗质量与患者安全面临的挑战，主要表现在医疗卫生体制改革明显滞后于其他行业；相关的法律规章和制度不健全；对高新技术及新材料的临床应用缺乏有效的规范化管理和准入制度；大部分医院都没有医疗风险管理的职能机构，在实际的运作中仅靠风险管理委员会或者院领导分管下的职能部门负责制，通过每月一次、二次的会议形式开展工作，往往不能解决日常运行中的实际问题，对照澳新风险管理标准AS/NZS4360标准，我科室的风险管理工作还存在不少问题和不足，例如：职工的风险管理意识不强，风险管理尚未纳入管理工作的全过程，许多的风险或隐患还没有被发现；针对现有风险的控制措施落实不充分，监控和信息沟通机制不够完善，等等。为了降低医疗不良事件的发生，提高医疗质量与保证患者安全，应用科学的方法强化科室风险管理是必要的。澳新风险管理标准AS/NZS4360如下图所示：2.风险管理2.1建立环境 2.1.1建立风险管理组织 成立心内科风险管理小组,由心内科主任、护士长、心内科主诊医师共同组成，负责风险管理工作的组织领导和重要决策。2.1.2明确风险管理责任和奖惩措施 建立风险管理责任体系，风险管理小组成员按照工作性质进行分工，分别负责组织开展本领域的风险管理日常工作。例如：护士长负责护理方面风险管理，主诊医师负责医院应急风险管理等，普通职工承担本岗位的风险防范工作。按照责任到人的原则，全体干部职工都要按照职责开展风险管理工作，并对发生的事故负责。普通员工对本岗位的风险防范和所发生的事故负直接责任，分管负责人对所负责的风险防范和所发生的事故负直接责任，主任负管理责任。对于在风险防范过程中做出贡献的，按照所承担责任的大小相应给予精神、物质、晋职等奖励，反之，对于导致发生事故的，相应给予通报、减薪、调离、等处罚。2.1.3 制定风险评价标准和识别关键元素 根据医疗事故处理条例、执业医师法医疗质量安全管理制度等相关法律法规，制定各种管理制度及质量标准，应用风险列举法和流程图法，通过头脑风暴、小组讨论等方式，对工作环境、工作过程、工作标准、工作流程和既往已发生的医疗缺陷、投诉事件、纠纷赔偿事件,以及患者满意度调查进行分析,发现存在的和潜在的风险。按照风险发生的可能性和后果的严重性，将风险分为低风险、中等风险、重大风险3个等级，以及可接受、可降低和不可接受3大类。确定制度、人员、仪器设备、操作流程、消防设施、计算机及网络、等一系列关键识别元素。将心内科的风险主要划分为：患者安全风险、环境风险、管理风险、医疗纠纷风险、人力资源风险、法律风险以及声誉风险等7种，并在此基础上，进一步深入识别、分析和处置风险。根据科室各病种特点，制定各种管理制度及质量标准，组织护士深入学习，熟记在心，成立以护士长为组长的病区管理小组，以主诊为组长的医生管理小组。2.2风险识别根据2.1.3中所确定的风险种类和识别关键元素，通过审计检查、头脑风暴、座谈、分组讨论等方式，结合历史资料以及投诉记录、事故报告和岗位职责等资料，识别已经存在的和可能发生的风险，并查找原因。2.3风险分析根据风险量化矩阵（表1），对风险的后果（表2、表3）可以根据对事态严重性、代价及进度等关键因素的潜在影响来考虑，分为不重要（Insignificant）、较微（Minor）、中度（Moderate）、重大（Major）、极端（Extreme）5种，分别用分值1-5衡量等级；对风险的可能性（表4）也就是风险发生的概率，可以分为几乎不可能（Remote）、不太可能（Unlikely）、可能（Possible）、很可能（Likely）、几乎确定（Almost certain）5种，也分别用分值1-5衡量等级。用两者乘积来测量风险：15分是低风险，615分是中等风险，16分以上是重大风险。Figure 1 Risk Quantification MatrixConsequenceLikelihood Insignificant1Minor2Moderate3Major4Extreme5Almost certain-5510152025Likely- 448121620Possible-33691215Unlikely-2246810Remote-111345LowMediumRisk: HighFigure 2 对科室安全事故后果的定性测评levelDescriptorDescription1极大（Extreme）造成患者功能障碍，经济损失2万元以上2重大（Major）事故可以解决但需要较长时间，造成患者明显人身损害，未造成功能障碍，经济损失1万元至2万元 3中等（Moderate）事故可以解决，患者及医护人员有轻度人身损害，损失在5000至1万元4较小（Minor）事故可以很快解决，没有患者及医护人员人身损害，经济损失5000元以下5可忽略（Insignificant）事故造成轻微影响，没有人身及经济损害Figure 3 可能性定性测评（Qualitative measures of likelihood）levelDescriptorDescription5几乎确定（Almost certain）绝大多数情况都会发生4很可能（Likely）多数情况下会发生3可能（Possible）有些情况下会发生2不太可能（Unlikely）少数情况下会发生1几乎不可能（Remote）极特殊情况下才会发生2.4风险评价根据2.3分析出来的风险与2.1.3开发的风险评价准则进行比较，综合考虑代价、资金和后果等因素，判断风险是否可接受或需要采取其它措施处置。对低风险或可接受的风险进行最小程度的处理，同时，进行监控和定期检查；对不可接受风险，采取降低风险或回避风险等处置措施。在此基础上，建立风险登记簿（表4）。表5是导致这些风险的内在和外在因素分析外脚手架搭设，悬挂安全网，铺设跳板，进行层间封闭，外脚手架上垃圾及杂物的清理,外脚手架的日常围护，配合外装单位做好外脚手架的修改，及时清理外脚手架上垃圾及杂物feelings survey, by looking up public sentiments to find problems. Problems will increase its special supervision, set up accounts, hold on to it. We should conscientiously implement the leading contracting matters, secured, had an answer to everything, then settles rate of 100%. Have an impact on some of the outstanding issues, supervision departments and information components together, play the supervisory role of the news media to promote problem solving. Investee 3. insist on a daily run, around the practice of truth catching efficiency, focus specification. To give full play to the party Office around connecting, coordinating internal and external features, contact, rally at all levels, to motivate every aspect, adhere to the truth, strengthening standardized management to achieve coherent, efficient and effective functioning of the daily work of the Party Committee. Is processing messages should strive to streamline, standardize and quality. Streamlining is to control the number of messages, compress messages, reducing procedures, improve message handling efficiency. Specifications, is to strictly enforce the ban issued by the Communist party authorities in document handling regulations and provincial and municipal regulations, conscientiously strengthen and improve communications management to ensure that party documents orderly. High quality, is to improve the quality of message processing, it is necessary to accurately implementing the intention of the Party Committee, clearance, good communications, policy program closed, ensuring that there is no error. Second meeting scheduled to ensure thorough, safe and efficient. Any arrangements for the meetings and events, carefully arranged, item-by-item interface implemented, sure. To vigorously streamline meetings, activities, number of pressure reduction, scale to ensure that leadership emerged from the General Conference and entertainment services, focus on big things, matters. Third, reception services should lay stress on humane, personal, cultural and human. Reception and work directly with people, reception services directly affecting the Office of party Committee The image of the region. At the same time strengthening the construction of library, improve the reception conditions, more human-oriented, personal, cultural work into the reception, a little more human needs, a little more human care more humane atmosphere, and constantly improve the service, improve the quality of service. Meanwhile, to further pay special attention to the daily work of the other Office System. Confidential work responsibility system for leading cadres to implement security as a leader, to improve the confidentiality of classified personnel, especially leading cadres, strengthening party and Government focus on vital sectors of security management, to advance privacy management standardization, modernization of security techniques as a means of administration according to law and security enforcement, ensure the safety of the party and State secrets. Confidential work to meet the demands of new technology development13Figure 4 Risk RegisterRisk IDRisk TypeRisk DescriptionActual or Potential risk?ConsequencesLikelihoodInitial Risk RatingRanking1患者安全风险护士未认真确认患者、未认真核对医嘱，发错药品、输错液体，造成医疗事故。A542012患者安全风险临床值班及交接班制度不良，致值夜班医师对病人病情评估不足，致主诊医师不在病房期间医疗问题难以解决A431213患者安全风险部分医护人员工作中，未严格执行手卫生规范，增加医院感染。P542014患者安全风险年青医师不注意心内科常用药物副作用，导致患者出现药物不良反应，不能及时发现及处理。A33915患者安全风险医师抢救危重症病人水平不一致，导致抢救成功率不高。P531516患者安全风险未能执行术前讨论制度，导致介入患者术前评估不足，不能预测可能出现的手术风险A441617设备故障风险定期设备维护工作不足，管理制度落实不良，致设备坏损后方修理，坏损率高，费用大影响正常使用P33938医疗纠纷风险部分医护人员缺乏与患者及家属良好沟通，出现医疗纠纷。P552519人力资源风险医护人员数量不足工作量大疲劳工作影响医疗质量及本人身体健康A4312210患者安全风险抢救设备及药品不齐备，导致抢救延误。P53151Management FactorsTeam FactorsTechnology FactorsExternal FactorsEnvironment FactorsStaff FactorsPatient FactorsIncident being explored执行力度不足授权和职责不清专业流程、应急方案存在缺陷专业知识不足政府对医院财力、人力投入不足设备投入不足工作能力不足对医务人员误解、不尊重患者周转快规章制度落实不到位领导能力差风险管理计划和治理措施不完善医护之间缺乏合作高龄、危重患者自我防护能力不足风险意识薄弱缺少责任心维修保障不完善医患关系紧张医保制度不健全Figure 5 - System Factors Contributing Adverse Events 工作强度大，过多劳累，积极性不高2.5风险处置对于可接受和可降低的风险，综合考虑措施的可行性、资金和代价等因素，在明确措施、责任、进度、预期结果等要求的基础上，制定治理计划（表6）。Figure 6 Treatment PlansRisk IDRisk DescriptionImplementation of risk reduction strategiesTime TableResponsibility for actionResidual riskConsequencesLikelihoodInitial Risk RatingRanking1护士未认真确认患者、未认真核对医嘱，发错药品、输错液体，造成医疗事故。 严格执行医嘱查对制度、三查八对制度、识别患者身份制度 每月培训一次，考核一次 护士长不定期的下病区抽查落实情况 患者实行腕带管理，实行护士移动工作站 建立奖惩制度，三个月总结一次长期执行护士长42812临床值班及交接班制度执行不够，值夜班医师对病人病情评估不足，致主诊医师不在病房期间医疗问题难以解决 强化值班、交接班制度 科主任不定期检查交接班记录，抽查值夜班医师执行情况 建立奖惩制度，三个月总结一次长期执行科主任22413部分医护人员工作中，未严格执行手卫生规范，增加医院感染。 落实医院感染管理规范，加强手卫生规范 不定期考核医护人员手卫生知识及洗手步骤长期执行护士长22424年青医师不注意心内科常用药物副作用，导致患者出现药物不良反应，不能及时发现及处理。 加强心血管药物知识培训、