護理安全管理質(zhì)量考核標準

護理安全管理質(zhì)量考核標準,,,,,

序號,檢查內(nèi)容,,,存在問題,分值

1,"高危

風險

管理

1.0",,"高危

患者

文件

管理",1.1高危患者無跌倒、墜床風險評估單,0.1

,,,,1.2高?；颊呷缗P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床頭卡等級護理標記不清,0.1

,,,,2.6床頭卡飲食標記不清,0.1

,,,,2.7床頭卡過敏史沒有標識,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)警標識,0.05

,,,,6.11器械外包裝上標識不清楚或無中文標識,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,,各種導管1.0,,7.1氧氣管無標識,0.1

,,,,7.2氧氣管打折、脫落,0.1

,,,,7.3尿管無標識、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,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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