血透室质控工作计划.doc

Leaders: provincial agricultural work Conference held in XX, which is our concern and love, will greatly promote XX agricultural and rural economic development. First of all, I am representing XX municipal party Committee and Government, extend a warm welcome to the attending leaders! XX has been given support and assistance to the province of agriculture, provincial agricultural Office, and expressed heartfelt thanks to all the friends! below, I XX with a brief report. A basic XX of XX municipality located (cities, omitted). One is the superior ecological environment. XX blue, clear, green, water, air, 70% of land in the territory is covered with forests, grasslands, wetlands and waters, built 7 thousands of square kilometers of the total area of nature reserves. Within major industrial pollution sources, air quality at the national level, national levels, water quality, soil pollution, pure land reputation, was heralded by the United Nations environmental officials the most suitable place for human survival. Second, the enrichment of natural resources. A total area of more than 5 million mu of arable land (which owned 1.53 million acres), the annual grain output of more than 2 million tons and is located in the internationally recognized gold cattle, there should be more than 400,000 acres of grazing grassland, developing animal husbandry conditions; a total area of 4.1 million acres of forest land, rich in precious wood such as pine, ash, yellow pineapple, standing timber volume of more than 26 million cubic meters. Forest Xia has hundreds of species precious wildlife, more than 200 more species precious herbs, annual Super thousand tons of wild mushroom and reserves Super 100,000 tons of mountain dish; nectar plant throughout, can bee 100,000 group, is China bee of Xiang, and national Northeast black bee reserves and important of bee products production base; can using water 2.5 billion cubic metres, should be fishing water 460,000 acres, rich big salmon, and three spent five Luo, North cold water specialty fish; found and proved reserves of mineral resources has 36 species. Third, geopolitical advantages. XX open midpoint is located in the eastern part of the province along the border, 264 km long border, with national road passenger and freight transport port, built on the border between China and Russia has the largest permanent boundary River Bridge, running at full capacity the annual cargo capacity of up to 2.6 million tons. Russia two (HABA and Marina), two cities (Iman and Lesozavodsk) is the Russian Far East in developed areas. Lesozavodsk is only 8 km from XX port corresponding to the port of markovo, Lu Rinuo station is one of three railway marshalling yards in the far East, the far East-Siberian railway and a parallel road runs through the pass. By rail and road, to the North by HABA capital Khabarovsk, the Russian hinterland, radiation in the CIS and Eastern European countries; to the South through the port of Vladivostok and the nahuo card on the sea, to reach South Korea, Japan and other Pacific Rim countries and regions. Four is rich in tourism resources. XX tourist resources types, many attractions, beautiful scenery of the Sino-Russian border-river-wusuli River, a famous treasure island, known as the Oriental Maginot line of the Japanese invading army Tiger underground fortress ruins, General Chi血透室质量控制计划血透室质控架构赖 丽 文主任医师（文，文主人主人主任住（祝 清 秀副主任医师曹玲英护 师喻 国 安主治医师何 贵 珍住院医师 江 燕护 师刘燕华护 师邹淑珍护 师张 欢护 师熊丹丹护 士游 佳护 师张俊虹护 士程清莲护 士钱宇鸿护 士 一、组成员分工赖丽文：1.负责血透室全面管理工作和质量控制工作。制定质控工作计划。2.定期查房，解决临床疑难问题。3.监督及评估透析质量及预防控制医院感染管理工作。4.按照透析规范化要求制定并实施透析中心的管理制度、常规和操作规程。5.安排医疗、教学、科研工作，组织业务学习和技术考核。祝清秀：1.在血液透析室主任的领导下，全面负责血液透析室的日常医疗、教学和科研工作。落实质控工作计划，并有工作记录。2.负责患者透析方案的制定和调整，遵循个体化透析方案。3.积极开展各种新技术、新疗法。4.严格执行医院感染管理等有关制度。5.贯彻持续质量改进，定期分析评估患者透析质量，不断提高透析效果。6.负责进修及新进入医师的培训和带教工作。7.加强国内外透析指南和规范学习，重视和积极参与科研工作。8.若有疑难，向上级医生汇报。喻国安：1.负责上午班。查房。2.经常巡视患者，及时处理各种并发症。3.监测和评估病人的透析质量；4.负责透析技术操作前患者及家属的沟通工作，填写知情同意书。5. 负责完善登记制度并每月检查各种登记本。6.记录统计血透室运行数据。7.定期对质量管理指标进行分析评价，对存在的问题有改进措施。8.完善和保管质量管理资料，体现持续改进。何贵珍：1.负责下午班，查房；2.经常巡视患者，及时处理各种并发症。3.监测和评估病人的透析质量；4.记录并保管好透析病人资料；5.每3个月填写质量报告表（包括本单位血透室的环境卫生学监测结果；透析用水、透析液的细菌计数、内毒素测定结果等）；6.严格执行医院感染管理等有关制度，若有疑难问题应及时向上级医师汇报。曹玲英：1、负责每月一次专科质量检查，病人护理质量管理的检查 2、负责科室固定资产管理 3、负责药品物品领取工作及耗材出入库登记 4、科室总体护理工作的安排和管理江 燕： 1、负责各种登记本的检查 2、护理安全检查 3、负责抢救车管理，每周定期对抢救车、药品物品进行检查；标签清楚，符合要求。药品管理合格率95分以上，急救设备维修保养，保证处于完好状态，管理合格率95分以上 4、工作人员手卫生，消毒隔离感染控制，职业防护培训 5、血管通路小组质控，负责每月一次病人血管通路评估工作，承担对血管通路的使用方法保护的指导工作 6、指导血管通路，组成员完成首次内瘘病人连续3次穿刺的宣教工作 7、护理质量统计表刘燕华：1、负责带教，安排教学，小讲课计划 2、负责每季一次科内理论，操作考核落实，并有记录 3、负责专科护士培训计划落实及每月一次透析紧急意外情况的处理预案流程进行培训演练及考核 4、负责对病人健康宣教落实，负责健康宣教计划制定 5、清点被服、床单、被罩并登记数量 6、负责查所有透析病人的费用，防止漏帐邹淑珍：1、负责一次性物品、无菌物品、药品的检查与整理，各类药物定点分类放置，标签清楚，保证无过期 2、负责环境管理 3、负责每月一次病人满意度调查，对其意见和建议进行记录，及时反馈张 欢：1、负责安排业务学习 2、协助本科护士的培训，理论及操作考核 3、负责“品管圈“活动的开展其他各成员：协助各质控组长工作，服从组长安排二、质控计划和要求1、实行质控三级管理 通过从参与质控的三级质控不定期进行检查，每周有日常质控记录，每月有总结工作，将存在问题组织讨论会，在科内整改2、质控方法1) 以质量考核标准为标准，组长、护士长随机进行自查，每月将内容集中反馈记录与质控本上，利用科室质控会进行讨论，不断改善血透质量。2) 落实三级质量管理制度，护理质量管理的要点从质控医生、护士到持续性教育，科主任、护士帮助护士指导护士，建立“责任医生、护士-组长-科主任、护士长”三级质控，通过查房，控制高危病人，高危技术操作，高危因素，建立前瞻性质量管理，提高血透质量，确保病人安全，每月根据科室制定的表格统计数据，以及日常质量考核进行分析，改善计划，通过质量分析，原因讨论，整改措施，不断改进工作，提高血透质量组长工作具体安排如下：星期一：病区管理，检查区内的水、电、空调的部分设施是否完好，及时维修，无安全隐患，病房整齐，无异味星期二：护士培训，检查组内每个护士的培训资料完成情况星期三：文件书写，检查每组每个护士主管病人的透析记录，按质控要求检查，将存在问题进行登记星期四：消毒隔离及医院感染1) 检查血透治疗室，血透准备室的无菌物品存放及灭菌符合要求，无过期物品。处置室的医疗垃圾按医疗废物分类放置2) 检查