醫院醫療品質及病人安全年度工作目標
目標 101-102年執行重點
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目標一:提升用藥安全
1.提升病人及照護者安全用藥的能力
2.加強慢性疾病病人用藥安全
3.落實用藥過敏及不良反應史的傳遞
4.運用資訊提升用藥安全
5.加強高警訊藥品的使用安全
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目標二:落實感染控制
1.落實手部衛生遵從性及正確性
2.落實抗生素使用管理機制
3.落實組合式照護(bundle care)的概念,降低醫療照護相關感染
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目標三:提升手術安全
1.落實手術辨識流程及安全查核作業
2.提升麻醉照護品質
3.落實手術儀器設備檢測作業
4.避免手術過程中造成的傷害
5.建立適當機制,檢討不必要之手術
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目標四:預防病人跌倒及降低傷害程度
1.落實執行跌倒風險評估及防範措施,尤其是特定族群如兒童、老人…等
2.提供安全的照護環境,降低跌倒傷害程度
3.跌倒後檢視及調整照護計畫
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目標五:落實病人安全異常事件管理
1.營造異常事件通報文化,並參與全國性病人安全通報系統
2.對異常事件進行分析
3.營造正向病安文化,建立異常事件相關人員支持系統
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目標六:提升醫療照護人員間的有效溝通
1.落實交接班資訊傳遞之完整與及時性
2.落實轉運病人之風險管理與標準作業程序
3.落實醫療照護人員間醫囑或訊息傳遞的正確性
4.落實檢驗、檢查、病理報告之危急值或其他重要結果及時通知與處理
5.加強團隊溝通技能
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目標七:鼓勵病人及其家屬參與病人安全工作
1.鼓勵醫療人員主動與病人及其家屬建立合作夥伴關係
2.提供民眾多元參與管道
3.鼓勵民眾通報所關心的病人安全問題
4.主動提供病人醫療安全相關資訊
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目標八:提升管路安全 1.落實管路使用之評估及照護
2.提升管路置放安全及減少相關傷害
3.加強團隊合作,提供整合性照護
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目標九、強化醫院火災預防與應變
1.加強防火設施(備)及管理
2.制訂全院及各單位之火災緊急應變計畫
3.落實人員防火教育及火警應變訓練
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新目標:加強住院病人自殺防治
1.加強環境安全
2.建立住院病人自殺風險評估機制
3.提供自殺高風險個案之個別化照護、溝通與支持◎建立照護及轉介機制affair dating sites
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