護理安全管理質(zhì)量考核標(biāo)準(zhǔn)

護理安全管理質(zhì)量考核標(biāo)準(zhǔn),,,,,

序號,檢查內(nèi)容,,,存在問題,分值

1,"高危

風(fēng)險

管理

1.0",,"高危

患者

文件

管理",1.1高?；颊邿o跌倒、墜床風(fēng)險評估單,0.1

,,,,1.2高危患者如臥床、重患皮膚有紅、腫、痛、破潰等無評估記錄,0.1

,,,,1.3跌倒事件上報不及時,0.2

,,,,1.4壓瘡上報不及時,0.2

,,,"防護

措施",1.5高?；颊?如：兒童、老年人、神志不清的患者)無床擋,0.2

,,,,1.6保護約束帶過緊或過松,0.1

,,,,1.7護理標(biāo)記不全，如防壓瘡、防跌倒溫馨提示卡,0.1

2,"患者

身份

識別

1.0",,腕帶管理,2.1無腕帶,0.1

,,,,2.2腕帶相應(yīng)顏色不正確、患者信息字跡不清、有涂改、無手術(shù)名稱,0.1

,,,,2.3腕帶顏色、信息與病人不符，與醫(yī)囑不符,0.1

,,,床頭卡管理,2.4無床頭卡,0.1

,,,,2.5床頭卡等級護理標(biāo)記不清,0.1

,,,,2.6床頭卡飲食標(biāo)記不清,0.1

,,,,2.7床頭卡過敏史沒有標(biāo)識,0.1

,,,,2.8床頭卡與醫(yī)囑、腕帶等級不符,0.1

,,,,2.9床頭卡無醫(yī)保標(biāo)識,0.1

,,,,2.10出院、轉(zhuǎn)科、死亡患者未及時撤下床頭卡,0.1

,,,制度流程知曉情況,3.1護士不清楚不良事件如何上報,0.05

,,,,3.2臨床突發(fā)事件處理預(yù)案不知曉,0.05

,,,,3.3提問護士應(yīng)急程序不清楚,0.05

,,,,3.4護理查對制度不知曉,0.05

3,"核心

制度

1.0",,制度流程知曉執(zhí)行,3.5護士值班交接班制度不知曉,0.05

,,,,3.6執(zhí)行醫(yī)囑制度不知曉,0.05

,,,,3.7未床頭交接班,0.1

,,,,3.8病房、手術(shù)室、ICU轉(zhuǎn)運未填寫對接單,0.1

,,,,3.9未遵守操作規(guī)程,0.1

,,,,3.10護士執(zhí)行操作未進行身份識別,0.1

,,,,3.11壓瘡患者未2小時翻身、未觀察受壓部位皮膚情況,0.1

,,,,3.12危急值未及時處理,0.1

,,,,3.13手術(shù)過程未進行安全核查,0.1

4,"手衛(wèi)生

0.5",,,4.1護士操作前后未洗手,0.2

,,,,4.2護士洗手方法不正確,0.3

5,藥品安全1.0,,,詳見第八章,1

序號,檢查內(nèi)容,,,存在問題,分值

6,"醫(yī)療

儀器

1.0",,常用醫(yī)療儀器,6.1無使用記錄,0.05

,,,,6.2未關(guān)機,0.05

,,,,6.3儀器未處于100％使用狀態(tài),0.05

,,,,6.4儀器丟失,0.1

,,,,6.5儀器有故障未及時報修，無標(biāo)識,0.1

,,,,6.6停機但未切斷電源,0.05

,,,急救醫(yī)療儀器,6.7未定量、定位放置,0.05

,,,,6.8器械品種或數(shù)目與賬目不符,0.05

,,,,6.9消毒器械超過有效期,0.05

,,,,6.10近失效期器械無預(yù)警標(biāo)識,0.05

,,,,6.11器械外包裝上標(biāo)識不清楚或無中文標(biāo)識,0.05

,,,,6.12儀器未做定期保養(yǎng)、檢修、及時更新,0.05

,,,,6.13急救物品有外借,0.1

,,,,6.14急救器械（喉鏡、簡易呼吸器、手電筒、血壓計等）有故障,0.05

,,,,6.15無交接、檢查記錄,0.05

,,,,6.16交接、檢查記錄未簽名蓋章,0.05

,,,,6.17護士對急救器械使用規(guī)范掌握不熟練,0.05

7,,各種導(dǎo)管1.0,,7.1氧氣管無標(biāo)識,0.1

,,,,7.2氧氣管打折、脫落,0.1

,,,,7.3尿管無標(biāo)識、時間過期、扭曲、脫出,0.15

,,,,7.4引流袋未及時更換,0.1

,,,,7.5胃管無標(biāo)識、打折、脫出,0.15

,,,,7.6經(jīng)脈留置針脫出、穿刺無時間、貼膜卷邊、留置過期、無微機工號,0.15

,,,,7.7預(yù)防管路滑脫措施落實不到位,0.1

,,,,7.8其他管路無標(biāo)識、扭曲,0.15

8,"病房

安全

管理

1.0",,,8.1人員離開時治療室未鎖門,0.05

,,,,8.2人員離開時值班室未上鎖,0.05

,,,,8.3人員離開時檢查室未上鎖,0.05

,,,,8.4人員離開時換藥室未上鎖,0.05

,,,,8.5廁所、走廊、病房地面濕滑、有水漬,0.1

,,,,8.6病房內(nèi)、樓梯通道有人吸煙,0.1

,,,,8.7安全通道封閉私自堆放雜物占用,0.1

,,,,8.8病房使用自帶電器,0.1

,,,,8.9床腳鎖未固定,0.1

,,,,8.10病歷丟失,0.1

,,,,8.11電腦丟失,0.1

,,,,8.12水龍頭未關(guān)閉,0.1

序號,檢查內(nèi)容,,,存在問題,分值

9,"輸血

管理

1.0",,,9.1輸血未進行雙人核對,0.2

,,,,,,

,,,,9.2輸血醫(yī)囑無護理記錄,0.1

,,,,9.3輸血記錄不完整,0.1

,,,,9.4連續(xù)輸入不同供血者的血液時兩袋血之間未用生理鹽水沖管,0.2

,,,,9.5輸血過程中速度未根據(jù)病情和年齡調(diào)整輸血速度,0.1

,,,,9.6輸血后空血袋未保留24小時,0.1

,,,,9.7取回血后，未在4小時之內(nèi)輸注,0.2

10,靜療安全管理1.5,,護士方面,10.1藥名不知曉,0.05

,,,,10.2劑量不知曉,0.05

,,,,10.3滴速不知曉,0.05

,,,,10.424小時液體量不知曉,0.05

,,,,10.5藥物作用不知曉,0.05

,,,,10.6副作用不知曉,0.05

,,,,10.7禁忌癥不知曉,0.05

,,,留置針管理,10.8貼膜卷邊,0.05

,,,,10.9貼膜已臟,0.05

,,,,10.10穿刺部位紅腫、痛，未采取護理措施,0.05

,,,,10.11留置針有回血，已凝,0.05

,,,,10.12留置針無穿刺時間、穿刺者工號,0.05

,,,,10.13貼膜下有滲血、滲液,0.05

,,,,10.14穿刺部位不規(guī)范（于下肢）,0.05

,,,液體管理,10.15長期輸液提前加藥時間超過1小時，未給藥,0.05

,,,,10.16配液加藥未執(zhí)行即簽字蓋章,0.05

,,,,10.17抗生素類藥物未現(xiàn)用現(xiàn)配,0.05

,,,,10.15長期輸液提前加藥時間超過1小時，未給藥,0.05

,,,,10.16配液加藥未執(zhí)行即簽字蓋章,0.05

,,,,10.17抗生素類藥物未現(xiàn)用現(xiàn)配,0.1

,,,,10.18在病房內(nèi)配液加藥,0.05

,,,,10.19打開的無菌液無標(biāo)記或無日期,0.05

,,,輸液巡視卡,10.20簽字模糊、字跡潦草，無法確認(rèn),0.05

,,,,10.21無輸液巡視卡,0.05

,,,,10.22無患者家屬簽字,0.05

,,,,10.23護士未簽滴速,0.05

,,,,10.24護士未簽時間,0.05

,,,,10.25護士未簽姓名,0.05

,,,,10.26提前寫滴速,0.05

,,,,10.27提前收回,0.05

,,,,10.28未及時收回,0.05

,,,,10.29滴速填寫與實際不符合,0.05

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