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提高抗腫瘤藥物操作的標(biāo)準(zhǔn)性品管圈|總結(jié)方案|動(dòng)態(tài)PPT|實(shí)用大氣|商務(wù)展示|此處添加詳細(xì)文字描述,建議與題目相關(guān)并符合整體語(yǔ)言風(fēng)格,此處添加詳細(xì)文字描述,建議與題目相關(guān)并符合整體語(yǔ)言風(fēng)格,+活動(dòng)方案擬定現(xiàn)狀把握目標(biāo)設(shè)定主題選定目錄DIRECTORY解析對(duì)策實(shí)施與檢討效果確認(rèn)標(biāo)準(zhǔn)化對(duì)策擬定檢討與改進(jìn)行業(yè)PPT模板主題選定01chapter主題選定——選題過(guò)程主題評(píng)價(jià)題目上級(jí)政策重要性迫切性圈能力總分順序選定輪轉(zhuǎn)護(hù)士的帶教303232361302

病區(qū)環(huán)境323228361283

冰箱藥品管理282824241045

穿刺工具選擇222434281084

提高抗腫瘤藥物操作的規(guī)范性403638361501★提高治療室物品放置規(guī)范率24241830966

分?jǐn)?shù)/人數(shù)重要性迫切性圈能力上級(jí)政策1次重要次迫切0~50%次相關(guān)3重

要迫

切51~75%相

關(guān)5極重要極迫切76~100%極相關(guān)主題選定——關(guān)于主題抗腫瘤藥物的操作包括:配制流程、給藥方式及操作流程藥物、外滲的應(yīng)急、預(yù)案化療廢棄物的處理。名詞解釋計(jì)算公式×低血壓發(fā)生的次數(shù)總調(diào)查次數(shù)100%血透過(guò)程中患者低血壓的發(fā)生率活動(dòng)主題:提高抗腫瘤藥物操作的標(biāo)準(zhǔn)性主題選定——選題理由保護(hù)了自身的健康,提高護(hù)理質(zhì)量,減少護(hù)理不良事件的發(fā)生。對(duì)同仁而言避免了不必要的醫(yī)患糾紛,提高了醫(yī)院的形象。對(duì)醫(yī)院而言病人用藥安全得到了保證,減少患者因化療藥物外滲而導(dǎo)致的費(fèi)用增加、住院時(shí)間延長(zhǎng)。對(duì)患者而言病人用藥安全得到了保證,減少患者因化療藥物外滲而導(dǎo)致的費(fèi)用增加、住院時(shí)間延長(zhǎng)。對(duì)護(hù)士而言活動(dòng)方案擬定02chapter

月份

周期活動(dòng)

項(xiàng)目2026年3月2026年4月2026年5月2026年6月2026年7月2026年8月2026年9月

負(fù)責(zé)人1周2周3周4周1周2周3周4周1周2周3周4周1周2周3周4周1周2周3周4周1周2周3周4周1周2周3周4周

選出圈名及圈徽

xxx

主題確定

xxx

活動(dòng)計(jì)劃擬定

xxx

現(xiàn)狀把握

xxx

目標(biāo)設(shè)定

xxx

原因解析

xxx

制定對(duì)策

xxx

對(duì)策實(shí)施

xxx

效果確認(rèn)

xxx

標(biāo)準(zhǔn)化

xxx

檢討及改進(jìn)

xxx

資料整理及發(fā)表

xxx活動(dòng)方案擬定現(xiàn)狀把握03chapter現(xiàn)狀把握缺陷項(xiàng)目缺陷例數(shù)累計(jì)百分比(%)化療防護(hù)設(shè)施不齊全4646.46靜脈給藥流程不合理3278.79抗腫瘤藥物處置不合理987.88護(hù)理人員防護(hù)意識(shí)不強(qiáng)693.94接收抗腫瘤藥物不合理598.99抗腫瘤藥物暴露處置不合理1100.00合計(jì)99

對(duì)象:2026年4月抗腫瘤藥物操作數(shù)99例時(shí)間:2026年4月1日—24日方法:數(shù)據(jù)收集現(xiàn)狀把握制表目的:現(xiàn)狀把握制表時(shí)間:2026.5.1制表人:xxx目標(biāo)設(shè)定04chapter目標(biāo)設(shè)定=32-(32×78.79%×90%)=9目標(biāo)值設(shè)定降低因靜脈給藥流程不合理而發(fā)生缺陷的目標(biāo)值目標(biāo)值02=現(xiàn)況值-(現(xiàn)況值×累計(jì)百分比×圈員能力)設(shè)定降低因抗腫瘤廢棄物處置不合理而發(fā)生缺陷的目標(biāo)值目標(biāo)值01=46-(46×46.46%×90.0%)=26目標(biāo)值解析05chapter解析為什么抗腫瘤藥物操作會(huì)不規(guī)范化療廢棄物專用垃圾桶少無(wú)專用化療操作箱專用容器缺乏標(biāo)識(shí)不清無(wú)靜脈給藥流程規(guī)程不夠細(xì)化與靜配室接藥流程缺乏化療藥物外滲應(yīng)急預(yù)案未更新抗腫瘤藥物暴露應(yīng)急預(yù)案不夠責(zé)任心不強(qiáng)防護(hù)意識(shí)不強(qiáng)防護(hù)意識(shí)不強(qiáng)化療知識(shí)防護(hù)信息更新慢防護(hù)知識(shí)缺乏與外院缺少學(xué)習(xí)交流人員配置不合理人力不足未按操作規(guī)程無(wú)充足的放置空間化療廢棄物無(wú)專門放置點(diǎn)空間狹小無(wú)專用放置容器護(hù)士設(shè)備環(huán)境操作流程解析2134治標(biāo)問(wèn)題點(diǎn):未嚴(yán)格控制滴速度解決問(wèn)題點(diǎn):未嚴(yán)格控制滴速度過(guò)渡問(wèn)題:未嚴(yán)格控制滴速度治本問(wèn)題點(diǎn):未嚴(yán)格控制滴速度對(duì)策擬定06chapter對(duì)策擬定WhatWhyHowWho決策判定WhenWhere主題重要原因?qū)Σ邤M定負(fù)責(zé)人可行性效果性自主性總分

提高抗腫瘤藥物操作的規(guī)范性

設(shè)備欠缺改進(jìn)化療廢棄物專用垃圾桶

xx

38

26

24

88

內(nèi)一科配備專用靜脈推注箱

xx

36

38

26

100

內(nèi)一科配備化療外濺箱

xxx

32

24

22

78

內(nèi)一科

防護(hù)意識(shí)淡薄進(jìn)行專業(yè)的培訓(xùn)

xxx

40

38

32

110

內(nèi)一科制定防護(hù)措施

xxx

36

33

30

99

內(nèi)一科更新防護(hù)知識(shí)

xxx

24

22

26

72

內(nèi)一科

操作規(guī)程少制定抗腫瘤藥物暴露的應(yīng)急預(yù)案

xxxx

34

26

28

88

內(nèi)一科制定靜脈給藥方式流程及方法

xxx

24

38

26

88

內(nèi)一科對(duì)策實(shí)施與檢討07chapter對(duì)策實(shí)施與檢討對(duì)策一對(duì)策名稱配備抗腫瘤藥物操作必須設(shè)備。主要因?qū)S迷O(shè)備不完善改善前對(duì)策實(shí)施對(duì)策處置

對(duì)策效果確認(rèn)1.抗腫瘤廢棄物與感染性垃圾混在一個(gè)垃圾桶內(nèi),沒(méi)有分開放置。2.護(hù)士進(jìn)行抗腫瘤藥物操作時(shí),端著治療盤去,防護(hù)不到位存在藥物暴露在空氣中的隱患。1.配備化療廢棄物專用垃圾桶,并保證其密封性,貼上醒目標(biāo)志。2.配備專用靜脈給藥箱,并備齊防護(hù)材料,保證操作的平安性。3.由專人定時(shí)檢查改進(jìn)后效果良好1.每天定時(shí)檢查化療廢棄物處置情況,是否符合標(biāo)準(zhǔn)。2.查看護(hù)士進(jìn)行操作的標(biāo)準(zhǔn)性對(duì)策實(shí)施與檢討對(duì)策二對(duì)策名稱建立流程和應(yīng)急預(yù)案主要因風(fēng)險(xiǎn)意識(shí)差,管理不完善。改善前對(duì)策實(shí)施對(duì)策處置

對(duì)策效果確認(rèn)1.科室無(wú)統(tǒng)一的操作流程,每個(gè)護(hù)士進(jìn)行處理的方法不一樣建立抗腫瘤藥物操作流程圖。制定抗腫瘤藥物暴露的應(yīng)急預(yù)案改進(jìn)后效果良好每位護(hù)士都能執(zhí)行操作流程和相應(yīng)的應(yīng)急預(yù)案對(duì)策實(shí)施與檢討對(duì)策三對(duì)策名稱加強(qiáng)對(duì)護(hù)士的培訓(xùn),增強(qiáng)責(zé)任心主要因護(hù)士防護(hù)意識(shí)淡薄改善前對(duì)策實(shí)施對(duì)策處置

對(duì)策效果確認(rèn)1.輪轉(zhuǎn)護(hù)士及新進(jìn)人員經(jīng)驗(yàn)缺乏。

2.護(hù)士防護(hù)意識(shí)淡薄,對(duì)化療廢棄物危害性認(rèn)識(shí)不夠1.由科室的腫瘤專科護(hù)士培訓(xùn)輪轉(zhuǎn)護(hù)士及新進(jìn)人員抗腫瘤藥物的所有操作。2.科室組織業(yè)務(wù)學(xué)習(xí),對(duì)化療藥物暴露的危害,外濺的處理進(jìn)行學(xué)習(xí)。3.進(jìn)行考核改進(jìn)后效果良好1.培訓(xùn)按時(shí)完成。2.護(hù)士能說(shuō)出化療藥物暴露在空氣中的危害,外濺處理流程符合標(biāo)準(zhǔn)效果確認(rèn)08chapter效果確認(rèn)項(xiàng)目改善前改善后備注調(diào)查日期

資料來(lái)源資料收集統(tǒng)計(jì)匯總

調(diào)查總例數(shù)308例312例

數(shù)據(jù)化療防護(hù)設(shè)施不齊全9例靜脈給藥流程不合理32例抗腫瘤廢棄物處置部合理46例護(hù)理人員防護(hù)意識(shí)不強(qiáng)6例接受抗腫瘤藥物不合理5例抗腫瘤藥物暴露處置不合理1例

化療防護(hù)設(shè)施不齊全9例靜脈給藥流程不合理5例抗腫瘤廢棄物處置部合理0例護(hù)理人員防護(hù)意識(shí)不強(qiáng)1例接收抗腫瘤藥物不合理0例抗腫瘤藥物暴露處置不合理0例

合計(jì)99例14例

改善后數(shù)據(jù)效果確認(rèn)效果確認(rèn)處方審核配置6.護(hù)士進(jìn)行調(diào)配作業(yè),每一步驟均雙重確認(rèn)7.護(hù)士在進(jìn)入配置間前應(yīng)洗手,換上防護(hù)用品。8在生物安全柜內(nèi)操作。9.嚴(yán)格執(zhí)行無(wú)菌技術(shù)操作原則,以防藥液污染而給護(hù)士造成不良后果;1.醫(yī)生確認(rèn)診斷2.醫(yī)生評(píng)估病情及檢驗(yàn)數(shù)值,確認(rèn)后進(jìn)行開立醫(yī)囑或選用合適化療方案。3.護(hù)士核對(duì)化療藥物記錄單與電腦醫(yī)囑的病人姓名、藥物、劑量、劑型,途徑、頻次。4.護(hù)士通過(guò)醫(yī)院信息平臺(tái)將醫(yī)囑傳遞給靜脈藥物配置中心5.藥師對(duì)其中的配伍禁忌、不合理的用藥進(jìn)行反饋,確認(rèn)相容性,修改醫(yī)囑,安排配置計(jì)劃,打印出配置標(biāo)簽。效果確認(rèn)傳送給藥13.護(hù)士向病人解釋藥物作用,副作用。14由兩人核對(duì)病人、藥物標(biāo)簽及化療藥物記錄單資料相符,并確認(rèn)輸注速率正確15護(hù)士確認(rèn)輸注過(guò)程無(wú)誤,預(yù)防化療藥物外滲,如有外滲情形,依外滲作業(yè)流程規(guī)范處理10.配置好了的化療藥品應(yīng)單獨(dú)密閉由專人傳送。11.護(hù)士根據(jù)醫(yī)囑點(diǎn)收及確認(rèn)化學(xué)藥物,并簽字。12.放入病房專用的密閉箱中存放效果確認(rèn)項(xiàng)目改善前改善后活動(dòng)成長(zhǎng)正/負(fù)向總分平均總分平均解決問(wèn)題能力212.3333.671.37↑責(zé)任心273353.890.89↑溝通協(xié)調(diào)171.89374.12.21↑自信心182374.12.1↑團(tuán)隊(duì)凝聚力202.22414.562.34↑積極性212.23384.221.99↑品管手法913643↑和諧度202.22394.332.11↑注:由圈員9人評(píng)分,每項(xiàng)最高5分,最低1分,總分45分標(biāo)準(zhǔn)化09chapter標(biāo)準(zhǔn)化檢討與改進(jìn)10chapter檢討與改進(jìn)活動(dòng)項(xiàng)目?jī)?yōu)點(diǎn)缺點(diǎn)或今后努力方向主題選定根據(jù)科室實(shí)際情況發(fā)現(xiàn)問(wèn)題,選出的主題與臨床護(hù)理工作息息相關(guān),迫切需要解決選定主題在切合實(shí)際的基礎(chǔ)上,力求多發(fā)現(xiàn)別人沒(méi)有發(fā)現(xiàn)的新問(wèn)題活動(dòng)計(jì)劃選定按圈能力擬定可行性計(jì)劃,圈員能夠按計(jì)劃、分工認(rèn)真實(shí)施突破固有思維模式,活用QCC手法現(xiàn)況把握詳細(xì)整理資料,收集數(shù)據(jù)資料跨度較小,不夠全面目標(biāo)設(shè)定圈員設(shè)定的目標(biāo)符合實(shí)際,具有可行性更加細(xì)化目標(biāo),爭(zhēng)取努力做到能力決定目標(biāo),目標(biāo)帶動(dòng)能力解析QCC手法運(yùn)用得當(dāng),深入分析加強(qiáng)QCC和專業(yè)學(xué)習(xí),提高圈員的洞察力,改善圈員的分析能力對(duì)策擬定群策群力,對(duì)策性強(qiáng)對(duì)策涉及面廣,個(gè)別對(duì)策超出圈能力對(duì)策實(shí)施與檢討對(duì)制定的對(duì)策,圈員都能積極實(shí)施,發(fā)現(xiàn)問(wèn)題及時(shí)反饋檢討少數(shù)難以完成的對(duì)策,尋找可替代的解決方法效果確認(rèn)圈運(yùn)作圈過(guò)程,圈員認(rèn)真分析統(tǒng)計(jì),達(dá)成預(yù)期目標(biāo)成績(jī)不是100%,我們可以做得更好標(biāo)準(zhǔn)化將圈運(yùn)作過(guò)程中的關(guān)鍵點(diǎn)制訂成標(biāo)準(zhǔn)化流程,便于推廣實(shí)施標(biāo)準(zhǔn)不是一成不變的,日常工作中有針對(duì)性的靈活運(yùn)用,不斷完善圈會(huì)運(yùn)作情形圈員都能積極參加圈活動(dòng),工作中主動(dòng)落實(shí)圈計(jì)劃,互幫互助圈活動(dòng)基本上是利用圈員的業(yè)余時(shí)間,充分體現(xiàn)了團(tuán)隊(duì)精神和大家的積極性殘留問(wèn)題QCC學(xué)習(xí)運(yùn)用欠靈活,知識(shí)掌握不夠,團(tuán)隊(duì)精神不夠。謝謝觀看|總結(jié)方案|動(dòng)態(tài)PPT|實(shí)用大氣|商務(wù)展示|此處添加詳細(xì)文字描述,建議與題目相關(guān)并符合整體語(yǔ)言風(fēng)格,此處添加詳細(xì)文字描述,建議與題目相關(guān)并符合整體語(yǔ)言風(fēng)格,Alltexts,pictureframes,flowcharts,ICONS,etc.canbeedited;所有文本、圖框、流程圖、圖標(biāo)等均可編輯;AllPPTpagesizes,backgroundsandotherformatsarere-edited;所有PPT頁(yè)面大小、背景等一切格式均再編輯;PPTtemplatewithtwopagesoficontemplate,formatcanbemodifiedwithPPTtemplateuse;PPT模板后附有兩頁(yè)圖標(biāo)模板,格式均可修改配合PPT模板使用;AllPPTtemplatedesigncanbemodifiedandeditedaccordingtothecontentsofdefenseorreportpaper;所有PPT模板設(shè)計(jì),均可根據(jù)工作匯報(bào)、畢業(yè)辯論、公開演講或者行業(yè)培訓(xùn)內(nèi)容進(jìn)展修改編輯;PPTsuitableformajorcategories,onlyaccordingtopersonalopinions,similarorsimilarmajorscanalsobeused;PPT適合專業(yè)大類,僅根據(jù)個(gè)人意見(jiàn),相近或類似行業(yè)、專業(yè)亦可使用;ThankyouverymuchforyourtrustanduseofthePPTtemplate!非常感謝您對(duì)PPT模板的信賴和使用!Alltexts,pictureframes,flowcharts,ICONS,etc.canbeedited;AllPPTpagesizes,backgroundsandotherformatsarere-edited;PPTtemplatewithtwopagesoficontemplate,formatcanbemodifiedwithPPTtemplateuse;AllPPTtemplatedesigncanbemodifiedandeditedaccordingtothecontentsofdefenseorreportpaper;PPTsuitableformajorcategories,onlyaccordingtopersonalopinions,similarorsimilarmajorscanalsobeused;ThankyouverymuchforyourtrustanduseofthePPTtemplate!Alltexts,pictureframes,flowcharts,ICONS,etc.canbeedited;AllPPTpagesizes,backgroundsandotherformatsarere-edited;PPTtemplatewithtwopagesoficontemplate,formatcanbemodifiedwithPPTtemplateuse;AllPPTtemplatedesigncanbemodifiedandeditedaccordingtothecontentsofdefenseorreportpaper;PPTsuitableformajorcategories,onlyaccordingtopersonalopinions,similarorsimilarmajorscanalsobeused;ThankyouverymuchforyourtrustanduseofthePPTtemplate!Alltexts,pictureframes,flowcharts,ICONS,etc.canbeedited;AllPPTpagesizes,backgroundsandotherformatsarere-edited;PPTtemplatewithtwopagesoficontemplate,formatcanbemodifiedwithPPTtemplateuse;AllPPTtemplatedesigncanbemodifiedandeditedaccordingtothecontentsofdefenseorreportpaper;PPTsuitableformajorcategories,onlyaccordingtopersonalopinions,similarorsimilarmajorscanalsobeused;ThankyouverymuchforyourtrustanduseofthePPTtemplate!Alltexts,pictureframes,flowcharts,ICONS,etc.canbeedited;AllPPTpagesizes,backgroundsandotherformatsarere-edited;PPTtemplatewithtwopagesoficontemplate,formatcanbemodifiedwithPPTtemplateuse;AllPPTtemplatedesigncanbemodifiedandeditedaccordingtothecontentsofdefenseorreportpaper;PPTsuitableformajorcategories,onlyaccordingtopersonalopinions,similarorsimilarmajorscanalsobeused;ThankyouverymuchforyourtrustanduseofthePPTtemplate!Alltexts,pictureframes,flowcharts,ICONS,etc.canbeedited;AllPPTpagesizes,backgroundsandotherformatsarere-edited;PPTtemplatewithtwopagesoficontemplate,formatcanbemodifiedwithPPTtemplateuse;AllPPTtemplatedesigncanbemodifiedandeditedaccordingtothecontentsofdefenseorreportpaper;PPTsuitableformajorcategories,onlyaccordingtopersonalopinions,simi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