2022年中医院医疗安全不良事件报告制度及工作流程 .pdf

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1、精品办公文档阳曲县中医医院医疗安全（不良）事件报告制度及工作流程医疗安全（不良）事件报告是发现医疗过错中存在的安全隐患、防范医疗事故、提高医疗质量、保障患者安全、促进医学发展和保护患者利益的重要措施。为达到卫生部提出的病人安全目标，落实建立与完善主动报告医疗安全（不良）事件与隐患缺陷的要求，制定本制度。一、目的规范医疗（不良）事件的主动报告，增强风险防范意识，及时发现医疗不良事件和安全隐患，将获取的医疗安全信息进行分析、反馈并从医院管理体系、运行机制与规章制度上及时又针对性的持续改进。二、原则建立不良事件报告制度监测行业性、自愿性、保密性、非处罚性和公开性的特征。行业性：仅限于医院内与患者安全

2、有关的部门，如临床医技、护理、后勤等。自愿性：医院各科室、部门和个人有自愿参与的权利，提高信息报告人的自愿行为，保证信息的可靠性。保密性：该制度对报告人医技报告中设计的其他人和部门的信息完全保密，报告人科通过网络、新建等多种形式具名或匿名报告，医务处等专人专职受理部门和管理人员将严格保密。非处罚性：本制度不具有处罚权，报告内容不作为对报告人或他人违章处罚的依据，也不作为对涉及人员和部门的处罚依据，不涉及人员的晋升、评比、奖惩。公开性：医疗安全信息在院内医疗相关部门公示，通过申请向自愿参加的科室精品办公文档开放分享医疗安全信息及其结果分享，用于医院和科室的质量持续改进，公开的内容仅限于事例的本身

3、信息，不需经认定和鉴定，不涉及报告人和被报告人的个人信息。三、医疗不良事件报告制度性质医疗不良事件报告制度是对国家强制性“重大医疗过失和医疗试过报告系统”的补充性质的医疗安全信息。是独立的、保密的、自愿的、非处罚性的医疗不良事件信息报告系统。它是收集强制性的医疗事故报告等信息系统收集不到的有关医疗安全信息及内容。是对医师定期考核办法的奖惩补充。四、处理程序当发生不良事件后，报告人可采取多种形式，如填写书面医疗不良事件报告表或电话报告给相关部门，报告事件发生的具体事件、地点、过程、采取的措施等相关内容，一般不良事件要求24-48 小时内报告，重大事件、紧急情况者应在处理的同时口头上报告给相关上级

4、部门，职能部门接到报告后立即调查分析事件发生的原因、影响因素及管理等各个环节并制定改进措施。针对科室报告的不良事件，相关职能部门组织相关人员分析，制定对策，及时消除不良事件造成的影响，尽量将医疗纠纷消灭在萌芽状态。医务科、护理部负责备案，每季度进行总结，依据评定标准，提出奖惩意见，经医疗质量管理委员会讨论，上报院长办公会决议。五、奖惩制度1、主动报告医疗质量安全不良事件并积极整改的科室与个人，情节轻重可减轻或免于处罚。如上报的事件对科室或医院从管理体系、运行机制、规章制度及岗位职责上的流程再造有显著帮助，促进质量获得重大改进者，每次给予适当文档编码:CL9U6V1D1F7 HT4P7K3F8H

5、10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6

6、Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L1

7、0U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编

8、码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U

9、6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F

10、7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P

11、7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3精品办公文档奖励。2、当事人或科室在医疗质量安全不良事件-级发生后未及时上报，导致事件进一步发展的，主管部门从其它途径获知的，视情节轻重给予处罚，由此引发纠纷或事故的，另按本院医疗纠纷处理办法处罚。3、发生医疗质量安全不良

12、事件未主动报告的个人或科室取消评优资格。文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H1

13、0 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y

14、5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10

15、U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码

16、:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6

17、V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7

18、 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3精品办公文档医疗不良事件处理流程文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:C

19、L9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1

20、D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 H

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22、F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10

23、ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P5L10U3文档编码:CL9U6V1D1F7 HT4P7K3F8H10 ZL6Y5P

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