2023年護(hù)理質(zhì)量目標(biāo)監(jiān)測(cè)項(xiàng)目表2-4-16

護(hù)理質(zhì)量目標(biāo)監(jiān)測(cè)項(xiàng)目表通用指標(biāo)序號(hào)工作目標(biāo)計(jì)算方法結(jié)果檢查頻次上季度/上月合格率比較↑/↓上報(bào)時(shí)間1患者轉(zhuǎn)入、轉(zhuǎn)出交接質(zhì)量合格率（95%）達(dá)標(biāo)率（%）=查檢患者轉(zhuǎn)入、轉(zhuǎn)出交接質(zhì)量達(dá)標(biāo)項(xiàng)目數(shù)/查檢患者轉(zhuǎn)入、轉(zhuǎn)出交接總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃2不良事件管理合格率（95%）合格率（%）=查檢合格項(xiàng)目數(shù)/查檢總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃3患者手術(shù)交接質(zhì)量合格率（95%）達(dá)標(biāo)率（%）=查檢患者手術(shù)交接質(zhì)量達(dá)標(biāo)項(xiàng)目數(shù)/查檢患者手術(shù)交接總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃4危急值管理合格率（95%）合格率（%）=查檢合格項(xiàng)目數(shù)/查檢總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃5住院患者跌倒風(fēng)險(xiǎn)管理合格率（95%）落實(shí)率（%）=查檢預(yù)防住院患者跌倒措施落實(shí)符合項(xiàng)目數(shù)/查檢預(yù)防住院患者跌倒措施落實(shí)總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃6患者身份識(shí)別管理合格率（100%）規(guī)范率（%）=查檢身份識(shí)別規(guī)范項(xiàng)目數(shù)/查檢身份識(shí)別總項(xiàng)目數(shù)×100%每月護(hù)理部質(zhì)控計(jì)劃7患者約束風(fēng)險(xiǎn)管理合格率（95%）合格率（%）=查檢患者約束風(fēng)險(xiǎn)管理質(zhì)量合格項(xiàng)目數(shù)/查檢患者約束風(fēng)險(xiǎn)管理總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃8責(zé)任護(hù)士病情掌握正確率（90%）正確率（%）=查檢責(zé)任護(hù)士病情掌握正確項(xiàng)目數(shù)/查檢責(zé)任護(hù)士病情掌握總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃9臨床輸血管理質(zhì)量合格率（95%）達(dá)標(biāo)率（%）=查檢臨床輸血管理質(zhì)量達(dá)標(biāo)項(xiàng)目數(shù)/查檢臨床輸血管理總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃10中醫(yī)特色健康教育知曉率（90%）知曉率（%）=查檢中醫(yī)健康教育知曉項(xiàng)目數(shù)/查檢中醫(yī)健康教育總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃11分級(jí)護(hù)理質(zhì)量合格率（95%）合格率（%）=查檢分級(jí)護(hù)理合格項(xiàng)目數(shù)/查檢分級(jí)護(hù)理總項(xiàng)目數(shù)×100%每月護(hù)理部質(zhì)控計(jì)劃12病房藥品管理合格率（95%）合格率（%）=查檢病房藥品管理合格項(xiàng)目數(shù)/查檢病房藥品管理總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃13手衛(wèi)生的依從性及正確性合格率（90%）合格率（%）=查檢合格項(xiàng)目數(shù)/查檢總項(xiàng)目數(shù)×100%每月護(hù)理部質(zhì)控計(jì)劃14特殊科室消毒隔離落實(shí)率（95%）合格率（%）=查檢合格項(xiàng)目數(shù)/查檢總項(xiàng)目數(shù)×100%每月護(hù)理部質(zhì)控計(jì)劃15消毒隔離質(zhì)量合格率（95%）合格率（%）=查檢合格項(xiàng)目數(shù)/查檢總項(xiàng)目數(shù)×100%每月護(hù)理部質(zhì)控計(jì)劃16護(hù)理文書書寫合格率（95%）合格率（%）=查檢中醫(yī)護(hù)理文書合格項(xiàng)目數(shù)/查檢中醫(yī)護(hù)理文書總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃17患者入院評(píng)估及護(hù)理記錄單書寫合格率（95%）合格率（%）=查檢患者入院評(píng)估及護(hù)理記錄單書寫合格項(xiàng)目數(shù)/查檢患者入院評(píng)估及護(hù)理記錄單書寫總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃18實(shí)施中醫(yī)護(hù)理方案合格率（95%）合格率（%）=實(shí)施中醫(yī)護(hù)理方案合格項(xiàng)目數(shù)/查檢實(shí)施中醫(yī)護(hù)理方案總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃19搶救車/箱藥品完備率（100%）合格率（%）=查檢符合項(xiàng)目數(shù)/查檢項(xiàng)目總數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃20搶救車/箱物品完備率（100%）合格率（%）=查檢符合項(xiàng)目數(shù)/查檢項(xiàng)目總數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃21急救儀器設(shè)備完備率（100%）合格率（%）=查檢急救物品完備項(xiàng)目數(shù)/查檢總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃22床旁心電監(jiān)護(hù)儀報(bào)警限設(shè)置正確（97%）正確率（%）=查檢正確設(shè)置心電監(jiān)護(hù)儀報(bào)警限的例數(shù)/查檢心電監(jiān)護(hù)儀報(bào)警限設(shè)置的總例數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃23危重患者護(hù)理質(zhì)量合格率（93%）落實(shí)率（%）=危重患者護(hù)理質(zhì)量合格率項(xiàng)目/查檢危重患者護(hù)理質(zhì)量總項(xiàng)目×100%每月護(hù)理部質(zhì)控計(jì)劃24壓力性損傷護(hù)理合格率（95%）合格率（%）=查檢壓力性損傷護(hù)理合格項(xiàng)目數(shù)/查檢壓力性損傷護(hù)理合格總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃25靜脈血栓預(yù)防護(hù)理措施落實(shí)合格率（95%）合格率（%）=查檢護(hù)理措施合格項(xiàng)目數(shù)/查檢護(hù)理措施總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃26住院患者疼痛評(píng)估護(hù)理合格率（95%）合格率（%）=住院患者疼痛評(píng)估護(hù)理合格項(xiàng)目數(shù)/住院患者疼痛評(píng)估護(hù)理總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃27中醫(yī)特色文件規(guī)范落實(shí)率（95%）落實(shí)率（%）=中醫(yī)特色文件規(guī)范落實(shí)項(xiàng)目數(shù)/中醫(yī)特色文件總數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃28中醫(yī)理療操作單記錄規(guī)范率（95%）規(guī)范率（%）=查檢規(guī)范項(xiàng)目數(shù)/查檢總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃29預(yù)防非計(jì)劃性拔管措施落實(shí)率（95%）落實(shí)率（%）=統(tǒng)計(jì)周期內(nèi)uex預(yù)防措施落實(shí)項(xiàng)目數(shù)/統(tǒng)計(jì)周期內(nèi)執(zhí)行預(yù)防uex干預(yù)措施總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃30中心靜脈質(zhì)量管理達(dá)標(biāo)率（95%）達(dá)標(biāo)率（%）=合格項(xiàng)目數(shù)/查檢總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃31危重患者護(hù)理質(zhì)量合格率（95%）合格率（%）=危重患者護(hù)理質(zhì)量合格項(xiàng)目數(shù)/查檢危重患者護(hù)理質(zhì)量總項(xiàng)目數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃32住院患者胰島素安全注射達(dá)標(biāo)率（98%）達(dá)標(biāo)率（%）=單位時(shí)間內(nèi)住院患者胰島素安全注射達(dá)標(biāo)例數(shù)/單位時(shí)間內(nèi)住院患者胰島素安全注射例數(shù)×100%每季度護(hù)理部質(zhì)控計(jì)劃33給藥錯(cuò)誤例數(shù)每月每月34輸血錯(cuò)誤例數(shù)每月每月35住院患者壓瘡發(fā)生率發(fā)生率（%）=壓瘡發(fā)生人數(shù)/住院患者總床日數(shù)×1000‰每月每月36住院患者跌倒/墜床發(fā)生率發(fā)生率（%）=跌倒墜床發(fā)生人次/住院患者總床日數(shù)×1000‰每月每月37住院患者跌倒傷害率傷害率（%）=同期住院患者中發(fā)生跌倒傷害例數(shù)/統(tǒng)計(jì)周期內(nèi)有記錄的患者跌倒例數(shù)每月每月38重復(fù)跌倒發(fā)生率發(fā)生率（%）=同期內(nèi)發(fā)生2次及以上跌倒病例數(shù)/統(tǒng)計(jì)周期內(nèi)有記錄的患者跌倒例數(shù)每月每月39ICU患者呼吸機(jī)相關(guān)性肺炎發(fā)生率發(fā)生率（%）=同期呼吸機(jī)相關(guān)性肺炎感染例次數(shù)/統(tǒng)計(jì)周期內(nèi)有創(chuàng)機(jī)械同期總?cè)諗?shù)×1000‰每月每月40中心導(dǎo)管相關(guān)血流感染發(fā)生率（包括CVC、PICC）發(fā)生率（%）=同期中心導(dǎo)管相關(guān)血流感染例次數(shù)/統(tǒng)計(jì)周期內(nèi)中心導(dǎo)管插管總?cè)諗?shù)×1000‰每月每月41導(dǎo)尿管相關(guān)感染發(fā)生率發(fā)生率（%）=同期留置導(dǎo)尿管患者中尿路感染例次數(shù)/統(tǒng)計(jì)周期內(nèi)患者留置導(dǎo)尿管總?cè)諗?shù)×1000‰每月每月42中醫(yī)護(hù)理操作燙傷發(fā)生率發(fā)生率（%）=同期熱療患者發(fā)生燙傷的例次數(shù)/統(tǒng)計(jì)周期內(nèi)熱療患者人日數(shù)×1000‰每月每月43中醫(yī)護(hù)理技術(shù)操作考核合格率（98%）合格