护理安全管理质量考核标准

护理安全管理质量考核标准,,,,,

序号,检查内容,,,存在问题,分值

1,"高危

风险

管理

1.0",,"高危

患者

文件

管理",1.1高危患者无跌倒、坠床风险评估单,0.1

,,,,1.2高危患者如卧床、重患皮肤有红、肿、痛、破溃等无评估记录,0.1

,,,,1.3跌倒事件上报不及时,0.2

,,,,1.4压疮上报不及时,0.2

,,,"防护

措施",1.5高危患者(如：儿童、老年人、神志不清的患者)无床挡,0.2

,,,,1.6保护约束带过紧或过松,0.1

,,,,1.7护理标记不全，如防压疮、防跌倒温馨提示卡,0.1

2,"患者

身份

识别

1.0",,腕带管理,2.1无腕带,0.1

,,,,2.2腕带相应颜色不正确、患者信息字迹不清、有涂改、无手术名称,0.1

,,,,2.3腕带颜色、信息与病人不符，与医嘱不符,0.1

,,,床头卡管理,2.4无床头卡,0.1

,,,,2.5床头卡等级护理标记不清,0.1

,,,,2.6床头卡饮食标记不清,0.1

,,,,2.7床头卡过敏史没有标识,0.1

,,,,2.8床头卡与医嘱、腕带等级不符,0.1

,,,,2.9床头卡无医保标识,0.1

,,,,2.10出院、转科、死亡患者未及时撤下床头卡,0.1

,,,制度流程知晓情况,3.1护士不清楚不良事件如何上报,0.05

,,,,3.2临床突发事件处理预案不知晓,0.05

,,,,3.3提问护士应急程序不清楚,0.05

,,,,3.4护理查对制度不知晓,0.05

3,"核心

制度

1.0",,制度流程知晓执行,3.5护士值班交接班制度不知晓,0.05

,,,,3.6执行医嘱制度不知晓,0.05

,,,,3.7未床头交接班,0.1

,,,,3.8病房、手术室、ICU转运未填写对接单,0.1

,,,,3.9未遵守操作规程,0.1

,,,,3.10护士执行操作未进行身份识别,0.1

,,,,3.11压疮患者未2小时翻身、未观察受压部位皮肤情况,0.1

,,,,3.12危急值未及时处理,0.1

,,,,3.13手术过程未进行安全核查,0.1

4,"手卫生

0.5",,,4.1护士操作前后未洗手,0.2

,,,,4.2护士洗手方法不正确,0.3

5,药品安全1.0,,,详见第八章,1

序号,检查内容,,,存在问题,分值

6,"医疗

仪器

1.0",,常用医疗仪器,6.1无使用记录,0.05

,,,,6.2未关机,0.05

,,,,6.3仪器未处于100％使用状态,0.05

,,,,6.4仪器丢失,0.1

,,,,6.5仪器有故障未及时报修，无标识,0.1

,,,,6.6停机但未切断电源,0.05

,,,急救医疗仪器,6.7未定量、定位放置,0.05

,,,,6.8器械品种或数目与账目不符,0.05

,,,,6.9消毒器械超过有效期,0.05

,,,,6.10近失效期器械无预警标识,0.05

,,,,6.11器械外包装上标识不清楚或无中文标识,0.05

,,,,6.12仪器未做定期保养、检修、及时更新,0.05

,,,,6.13急救物品有外借,0.1

,,,,6.14急救器械（喉镜、简易呼吸器、手电筒、血压计等）有故障,0.05

,,,,6.15无交接、检查记录,0.05

,,,,6.16交接、检查记录未签名盖章,0.05

,,,,6.17护士对急救器械使用规范掌握不熟练,0.05

7,,各种导管1.0,,7.1氧气管无标识,0.1

,,,,7.2氧气管打折、脱落,0.1

,,,,7.3尿管无标识、时间过期、扭曲、脱出,0.15

,,,,7.4引流袋未及时更换,0.1

,,,,7.5胃管无标识、打折、脱出,0.15

,,,,7.6经脉留置针脱出、穿刺无时间、贴膜卷边、留置过期、无微机工号,0.15

,,,,7.7预防管路滑脱措施落实不到位,0.1

,,,,7.8其他管路无标识、扭曲,0.15

8,"病房

安全

管理

1.0",,,8.1人员离开时治疗室未锁门,0.05

,,,,8.2人员离开时值班室未上锁,0.05

,,,,8.3人员离开时检查室未上锁,0.05

,,,,8.4人员离开时换药室未上锁,0.05

,,,,8.5厕所、走廊、病房地面湿滑、有水渍,0.1

,,,,8.6病房内、楼梯通道有人吸烟,0.1

,,,,8.7安全通道封闭私自堆放杂物占用,0.1

,,,,8.8病房使用自带电器,0.1

,,,,8.9床脚锁未固定,0.1

,,,,8.10病历丢失,0.1

,,,,8.11电脑丢失,0.1

,,,,8.12水龙头未关闭,0.1

序号,检查内容,,,存在问题,分值

9,"输血

管理

1.0",,,9.1输血未进行双人核对,0.2

,,,,,,

,,,,9.2输血医嘱无护理记录,0.1

,,,,9.3输血记录不完整,0.1

,,,,9.4连续输入不同供血者的血液时两袋血之间未用生理盐水冲管,0.2

,,,,9.5输血过程中速度未根据病情和年龄调整输血速度,0.1

,,,,9.6输血后空血袋未保留24小时,0.1

,,,,9.7取回血后，未在4小时之内输注,0.2

10,静疗安全管理1.5,,护士方面,10.1药名不知晓,0.05

,,,,10.2剂量不知晓,0.05

,,,,10.3滴速不知晓,0.05

,,,,10.424小时液体量不知晓,0.05

,,,,10.5药物作用不知晓,0.05

,,,,10.6副作用不知晓,0.05

,,,,10.7禁忌症不知晓,0.05

,,,留置针管理,10.8贴膜卷边,0.05

,,,,10.9贴膜已脏,0.05

,,,,10.10穿刺部位红肿、痛，未采取护理措施,0.05

,,,,10.11留置针有回血，已凝,0.05

,,,,10.12留置针无穿刺时间、穿刺者工号,0.05

,,,,10.13贴膜下有渗血、渗液,0.05

,,,,10.14穿刺部位不规范（于下肢）,0.05

,,,液体管理,10.15长期输液提前加药时间超过1小时，未给药,0.05

,,,,10.16配液加药未执行即签字盖章,0.05

,,,,10.17抗生素类药物未现用现配,0.05

,,,,10.15长期输液提前加药时间超过1小时，未给药,0.05

,,,,10.16配液加药未执行即签字盖章,0.05

,,,,10.17抗生素类药物未现用现配,0.1

,,,,10.18在病房内配液加药,0.05

,,,,10.19打开的无菌液无标记或无日期,0.05

,,,输液巡视卡,10.20签字模糊、字迹潦草，无法确认,0.05

,,,,10.21无输液巡视卡,0.05

,,,,10.22无患者家属签字,0.05

,,,,10.23护士未签滴速,0.05

,,,,10.24护士未签时间,0.05

,,,,10.25护士未签姓名,0.05

,,,,10.26提前写滴速,0.05

,,,,10.27提前收回,0.05

,,,,10.28未及时收回,0.05

,,,,10.29滴速填写与实际不符合,0.05

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