First, the nursing department meeting system

(1) nurses' meeting in the whole hospital: organized by the nursing department, once a year 1 time, to summarize the completion of the annual nursing work and arrange the next work plan.

(2) Head nurse meeting: organized by the nursing department once a month to analyze and summarize the situation and existing problems of nursing quality, put forward improvement measures and arrange work priorities for next month.

(3) Working meeting of quality management committee: organized by nursing department once a month to analyze the problems existing in nursing quality and continuously improve the quality.

(4) Working meeting of nursing department: once a week, summarizing this week's work and setting the focus of next week's work.

Second, the nursing quality management committee work system

(1) The nursing quality management committee works under the direct leadership of the director in charge and the director of the nursing department.

(two) timely convey the relevant documents or notices.

(3) The Nursing Quality Management Committee holds a working meeting once a month to analyze the current situation of nursing quality and put forward improvement measures to ensure the continuous improvement of nursing quality. Summarize one month's work and arrange next month's work.

(4) The Nursing Quality Management Committee regularly and irregularly supervises the nursing quality of each department.

(five) held a meeting of the head nurse every month, informed the quality control results, the deployment of quality control work next month.

Three, nursing rounds, consultation, case discussion system

(A) Nursing rounds system

1. rounds of nursing department: organized by nursing department, every month 1 time, to check the completion of nursing work and the implementation of rules and regulations in each ward, and effectively solve the nursing management problems in the ward.

2. Department rounds: the head nurse of the department organizes nursing rounds once a month, and each department takes turns to organize them; The department organizes two rounds of nursing service every month. Responsible person, actively prepare materials and make records.

3. Teaching rounds: every month 1 time, discuss and analyze the nursing problems of typical cases, and keep records. 4. In general, all nursing staff should attend except the personnel on duty.

(2) Consulting system

1. In case of complicated nursing problems, the nurse in charge or the head nurse shall propose, organize nursing consultation in the department and make records.

2. Cross-departmental consultation, in case of serious illness, immediately apply for consultation in the corresponding department, and the head nurse or supervisor and above nurses will write the consultation application form. The invited department must be on call. Send experienced supervisors and nurses for consultation, and fill in consultation records.

3. In-hospital consultation, proposed and presided over by the head nurse or the head nurse, invited relevant personnel for consultation, and nursing department was attended.

4. Consultation should be fully discussed. When there is any objection, the host decides the consultation opinion and nursing plan. Finally, the host makes a summary.

(3) case discussion system

1. In case of difficulties, serious cases, new projects and new technologies, case discussion should be conducted.

2. The person in charge has complete information and records the discussion results in detail.

3. The host should make a final summary.

4. The head nurse should participate in case discussion.

Four, the head nurse administrative night rounds system

(a) arranged by the department, ward head nurse night rounds, on duty time arranged by the nursing department. When making rounds at night, exercise the functions and powers of the nursing department, assist in handling major and unexpected events in nursing work, ask for instructions and report to the relevant departments and nursing department in time, and ensure the normal operation of all nursing work in the hospital.

(2) according to the requirements of the nursing department, patrol wards, and evaluate the nursing quality of the patrol wards as required.

(3) Do a good job in quality control of night care. If a large-scale rescue occurs, you should go to the scene to assist the hospital leaders in organizing and commanding and participate in the rescue.

(4) The head nurse on duty should go to the nursing department to get the relevant information of rounds before 5 pm on the same day, and submit the duty record to the nursing department at work the next day, and make an oral report.

(five) the head nurse night administrative rounds as a reference for year-end assessment.

Five, nursing safety management system

(a) strictly abide by the hospital health management laws, administrative regulations, departmental rules and norms of diagnosis and treatment, and abide by the professional ethics of medical services.

(2) Strictly abide by the rules and regulations of the hospital, conscientiously implement the nursing work system, technical operation rules and aseptic technology operation principles, carry out all nursing work with a scientific and rigorous attitude, concentrate and be meticulous, and do not talk about things unrelated to work.

(3) Conscientiously implement the system of duty and succession, abide by labor discipline, stick to their posts, do not leave their posts without leave, do not leave their posts empty, earnestly perform their duties, patrol the wards in time according to the grading nursing standards, and closely observe the patient's condition changes. Handover should be made orally, in writing and by the patient's bedside, so as to be clear and clear. Those who have not completed the work or whose work quality is not up to standard shall not be handed over.

(4) Seriously implement and implement the check system, and strictly abide by the principle of three checks and eight pairs in all nursing operations such as infusion, blood transfusion, injection and medication. Every time BANCHA should check the doctor's advice once a week, and record it in time after each check.

(five) strictly implement the system of doctor's advice, in addition to rescue patients do not perform oral doctor's advice. Nurses must repeat the oral orders given by doctors when rescuing patients and performing operations, and can only implement them after the doctors check the drugs, and keep ampoules to urge doctors to fill in the orders in time.

(6) Before the drug allergy test, the matters needing attention should be explained and signed by the patient or his family before implementation. If there is a family allergic history or false positive, it should be signed by a doctor before taking the medicine, and should be observed after taking the medicine.

(7) Strictly carry out the operation procedures with oxygen, do four points for attention in oxygen use, place empty oxygen cylinders and full oxygen cylinders respectively, and pay attention to whether there is any air leakage in the central oxygen inhalation pipeline and oxygen inhalation device, and report and handle any abnormality in time.

(8) Earnestly implement the drug management system, hand over the rescue drugs in each shift, and ensure that the accounts, materials and cards are consistent, and replenish them in time after use. Specialists and head nurses must check once a week to ensure that the categories are complete, not expired and not deteriorated. Poisonous and hemp psychotropic drugs must be kept strictly, and each shift should be managed by a special person. Drugs in the treatment room shall be classified and placed, and it is forbidden to mix and misplace them.

(9) The rescue instruments and articles shall be managed by special personnel, so as to be positioned and placed, managed by special personnel, regularly checked and maintained in time, disinfected regularly, and kept in a standing state, and shall not be arbitrarily misappropriated or lent.

(10) Before operation, the patient should meet with the patient in the ward and check it carefully, and then check it again in the operating room, and indicate that the patient's check is correct. Before and after the operation, the items used in the operation must be carefully counted and double-signed, and escorted back to the ward after the operation, and the condition, treatment methods and precautions should be carefully explained.

(1 1) The supply room should manage the departments in strict accordance with the technical specifications for hospital infection management and disinfection, and conduct regular monitoring. Articles that do not meet the aseptic requirements, expired packages and incomplete packages shall not be distributed to the clinic. Disposable medical supplies must be standardized management, strictly controlled, sampled and monitored, and can be issued for clinical use only after passing the inspection.

(twelve) all hospitalized patients must explain the contents of the hospitalization notice to them, and ask the patients to sign the hospitalization notice.

Six, the key departments of nursing supervision system

(1) Key departments include: ICU, emergency department, operating room and supply room.

(two) according to the relevant requirements of the national hospital management, respectively, to develop key departments of nursing quality management standards.

(3) The head nurse of the department manages and supervises the nursing work in strict accordance with the requirements of quality standards.

(4) The nursing quality control team conducts a centralized inspection on the nursing work of the above departments once a month and reports the results to the nursing department.

(5) The nursing department should strengthen the key monitoring of the above departments, check them irregularly once a month, and make rectification within a time limit when problems are found.

(6) According to the inspection results of quality control team and nursing department, the department formulates improvement measures and organizes their implementation.

Seven, the key link of nursing management system

(1) The key links include the following:

1. Key links: patient handover, correct identification of patient information, drug management, perioperative period, patient pipeline management, pressure ulcer prevention, invasive nursing operation, and doctor-nurse connection.

2. Key time periods: noon, night shift, continuous shift, holidays and busy work.

3. Key patients: difficult and critical patients, newly admitted patients, surgical patients, elderly patients, patients receiving special examination and treatment, and patients with suicidal tendencies.

4. Key employees: nursing backbones, practice nurses, new nurses, senior nurses and nurses who have recently encountered life events.

(2) Strictly implement the hospital's medical core system, nursing operation procedures and job responsibilities.

(3) According to the key links and working characteristics of the ward, the ward puts forward and implements specific and effective nursing management measures to ensure the safety of patient care.

(4) The head nurse should organize relevant personnel to strengthen the shift management and personnel management in key periods, scientifically and reasonably arrange manpower according to the specific conditions of the ward, and have clear and specific requirements for the work, personnel and work connection in key periods, which are reflected in the shift scheduling.

(five) according to the ability and experience of nurses, arrange the nursing work of key patients, check and evaluate the nursing effect in time, strengthen the handover, inspection and observation of the condition of key patients, and reflect it in the nursing records.

Eight, nursing quality defect management system

Nursing quality defect refers to all phenomena and results that do not meet the nursing quality standards due to various reasons.

(1) Each ward should establish a nursing quality defect register, and analyze and record the nursing quality defects in time.

(two) after the occurrence of nursing quality defects, in line with the principle of patient safety first, take remedial measures quickly to avoid or reduce the damage to patients' own health or minimize the damage.

(3) The parties concerned should immediately report to the head nurse, who should report the process, causes and consequences of nursing quality defects step by step, fill in the analysis records of nursing quality defects, and report them to the nursing department within 24~48 hours, and the nursing department will put forward treatment opinions according to the defect plot and its influence on patients.

(4) All relevant records, inspection reports, medicines and instruments that caused the accident shall be properly kept, and shall not be altered or destroyed without authorization for identification.

(five) after the defect occurs, the ward should organize nursing staff to discuss, analyze the reasons, raise awareness, learn lessons and improve the work.

(six) the ward or individual with defects in nursing quality intentionally conceals it and is found by the leader or others afterwards, depending on the seriousness of the case.

(7) The nursing department regularly organizes relevant personnel to analyze various defects in nursing quality and continuously improve nursing quality.

Nine, nursing complaint management system

(a) all medical care work, due to service attitude, service quality or technical reasons, as well as the patient's own reasons, caused by dissatisfaction with the nursing work, in writing or orally reflected to the nursing department or the relevant departments to turn back to the nursing department, are all nursing complaints.

(2) The nursing department has designated personnel to receive nursing complaints, listen carefully to the complainant's opinions, be patient and calm down, and make complaint records.

(three) the receptionist should do a good job of explanation, to avoid causing new contradictions.

(4) The nursing department has a special nursing complaint register to record the causes, analysis, treatment and corrective measures of complaints.

(5) After receiving nursing complaints, the nursing department should give timely feedback, investigate and verify, and notify the head nurse of relevant departments. Departments should carefully analyze the cause of the incident, sum up experience, accept lessons, and put forward their own opinions and rectification measures.

(6) After the complaint is verified, the nursing department and relevant departments will give the parties corresponding treatment according to the severity of the incident.

Ten, nursing abnormal information reporting and processing system

(1) Abnormal nursing information includes:

1. Abnormal information of patients/family members: blood transfusion reaction, blood transfusion reaction, air embolism, extravasation of chemotherapy drugs, wrong execution of doctor's orders, catheter falling off, falling down, bed falling, scald, aspiration, inevitable pressure sore, pressure sore in hospital, suicidal tendency, sudden death, detention, mental symptoms, serious illness without escort, and accidental injury of family members of hospitalized patients.

2. Abnormal information of ward management: major rescue activities and rescue treatment of special cases, environmental, personnel and work problems that seriously affect patients' physical and mental health, sudden emergencies such as water stoppage, flooding, power failure, theft, affray, fire, earthquake, chemical agent/toxic gas leakage in ward, etc.

(2) When patients/family members are found to have the above-mentioned abnormal conditions, they should immediately organize relevant personnel to deal with them actively and effectively, and report to the competent leader at the same time, fill in the Nursing Abnormal Information Report Form and report it to the nursing department.

(3) The nursing department organizes relevant personnel to discuss, comprehensively analyzes the nature of abnormal information and the degree of influence on patients, puts forward treatment opinions, and guides, supervises and evaluates the implementation of various departments to realize the continuous improvement of nursing quality.

(5) When abnormal information is found in ward management, timely submit a written report on the occurrence and solution of the problem to the relevant departments in the hospital.

Eleven, nursing staff scheduling system

(a) the time schedule should reflect the principles of fairness, efficiency, reasonable structure and meeting the needs.

(2) Scheduling should follow certain rules, and flexible scheduling should be implemented according to the actual situation of nursing work to meet the needs of patients and ensure the normal progress of nursing work.

(three) the ward to implement two shifts, conditional wards should implement the "March 8th" shift system.

(four) clear the responsibilities of each shift, to ensure that the work handover is orderly, no mistakes.

(5) Scheduling should balance the workload of each class, properly match nurses of different levels, and give full play to the role of nurses with different seniority and titles.

(6) In case of emergency, the head nurse can be dispatched as needed.

Twelve, nursing staff training and assessment system

(a) the training object is all nursing staff. The nursing department, departments and wards are organized in the same way, with self-study as the main part and collective teaching as the supplement. Each department makes a study plan according to the characteristics of nursing staff and carries out hierarchical training.

(2) The nursing department conducts training on new knowledge, new business and new methods for nursing staff in the whole hospital every two months.

(3) Ward nursing staff training is conducted by the head nurse according to the related contents of nurses with different professional titles combined with three basics and three strictness.

(four) require the training of nursing staff to attend on time and make records.

(five) regularly organize nursing staff to carry out three basic and three strict inspections, register the results, and save the original data for future reference.

1. The nursing department organizes the basic nursing theory examination every year, and the participants account for 50- 100% of the nursing staff in the hospital. Assess the nursing skills once a month, and the participants account for 25-50% of the nursing staff in the hospital.

2. The head nurse organizes a basic theory assessment every six months and reports the results to the nursing department.

3. The head nurse of the department organizes an assessment of basic nursing theory or skills once a month.

(6) The nursing department purposely sends nurses out for further study, study and training, and gives reports or lectures to the nurses in the whole hospital.

Thirteen, nursing new personnel management system

(a) the scope of new nursing staff:

1. new nurse (working within one year);

2. Nursing interns (technical secondary school, junior college, undergraduate course, graduate student);

3. Senior nurse.

(2) Job requirements:

1. For the management of new nursing staff, there must be specialized personnel in the ward, and designated personnel to teach.

2. The teaching staff should strengthen the guidance and training for the new staff's professional business, and lead them to complete all kinds of nursing work.

3. The new nursing staff shall not independently engage in clinical nursing work, and shall not independently execute the doctor's advice, sign and be on duty.

4. Newcomers should strictly abide by the working system and operating procedures of hospitals and departments, and respect and obey the teaching teachers and head nurses.

5. I shall bear the main responsibility for the consequences caused by the new employee's unauthorized nursing operation or violation of various work systems and operating procedures.

Fourteen, the new nurse training system

(1) The nursing department provides a one-week pre-job training for newly graduated nursing staff on basic courses. The contents include: nursing rules and regulations, operating procedures, quality requirements of nursing staff, nursing safety, hospital infection control, writing norms of nursing documents, nursing laws and regulations, etc.

(2) Write personal experience after pre-job training.

(3) During the probationary period of new nurses (one year), the nursing department and the head nurse in the ward will continue to train new students. The contents include: basic nursing and specialist nursing technical operation, application of nursing procedures, specialist nursing routine and condition observation, specimen inspection methods, storage and application of drugs, various working procedures and requirements in the ward, methods of checking doctor's orders, demonstration of first-aid procedures, use of first-aid instruments, etc.

(4) After the probation period expires, the nursing department will organize a theoretical examination, and the head nurse of the department and the head nurse of the ward will comprehensively evaluate the new nurse. Only after passing the qualification and obtaining the practicing certificate can they be transferred to the practice nurse.

(five) the newly graduated nurses still can't undertake the clinical nursing work after training, according to the relevant provisions of the hospital.