【正文】 ......31五、加強(qiáng)特殊藥物的管理，提高用藥安全...................................................................................................32六、臨床“危急值”報告制度....................................................................................................................33七、防范與減少患者跌倒、墜床等意外事件發(fā)生... .................................................................................34八、防范與減少患者壓瘡發(fā)生....................................................................................................35九、妥善處理醫(yī)療安全（不良）事件...............................................................................................36十、患者參與醫(yī)療安全............................................................................................................................37第四章　醫(yī)療質(zhì)量安全管理與持續(xù)改進(jìn) ................................................................................................38一、醫(yī)療質(zhì)量管理組織.................................................................................................................................38二、醫(yī)療質(zhì)量管理與持續(xù)改進(jìn).....................................................................................................................40三、醫(yī)療技術(shù)管理........................................................................................................................................43四、臨床路徑與單病種質(zhì)量管理與持續(xù)改進(jìn)（可選，縣醫(yī)院為必選）...............................................46五、住院診療管理與持續(xù)改進(jìn).....................................................................................................................48六、手術(shù)治療管理與持續(xù)改進(jìn).....................................................................................................................54七、麻醉管理與持續(xù)改進(jìn)............................................................................................................................58八、重癥醫(yī)學(xué)管理與持續(xù)改進(jìn)（可選，縣醫(yī)院為必選）........................................................................63九、感染性疾病管理與持續(xù)改進(jìn)................................................................................................................66十、中醫(yī)管理與持續(xù)改進(jìn)............................................................................................................................69十一、康復(fù)治療管理與持續(xù)改進(jìn)................................................................................................................71十二、疼痛治療管理與持續(xù)改進(jìn)（可選）....................................................................................................73十三、精神科疾病的管理與持續(xù)改進(jìn)（可選）.........................................................................................75十四、藥事和藥物使用管理與持續(xù)改進(jìn)....................................................................................................78十五、臨床檢驗(yàn)管理與持續(xù)改進(jìn)................................................................................................................88十六、病理管理與持續(xù)改進(jìn).........................................................................................................................96十七、醫(yī)學(xué)影像管理與持續(xù)改進(jìn)...............................................................................................................103十八、輸血管理與持續(xù)改進(jìn)......................................................................................................................106十九、醫(yī)院感染管理與持續(xù)改進(jìn)..............................................................................................................112二十、血液凈化管理與持續(xù)改進(jìn)（可選，縣醫(yī)院為必選）..................................................................118二十一、醫(yī)用氧艙管理與持續(xù)改進(jìn)（可選）...........................................................................................124二十二、其他特殊診療管理與持續(xù)改進(jìn)（可選）..................................................................................127二十三、病歷（案）管理與持續(xù)改進(jìn)......................................................................................................131第五章　護(hù)理管理與質(zhì)量持續(xù)改進(jìn)........................................................................................................136一、確立護(hù)理管理組織體系.......................................................................................................................136二、護(hù)理人力資源管理...............................................................................................................................138三、臨床護(hù)理質(zhì)量管理與改進(jìn)...................................................................................................................141四、護(hù)理安全管理.......................................................................................................................................145五、特殊護(hù)理單元質(zhì)量管理與監(jiān)測...........................................................................................................147第六章　醫(yī)院管理 ...................................................................................................................................151一、依法執(zhí)業(yè)...............................................................................................................................................151二、明確管理職責(zé)與決策執(zhí)行機(jī)制，實(shí)行管理問責(zé)制. .........................................................................153三、依據(jù)醫(yī)院的功能任務(wù)，確定醫(yī)院的發(fā)展目標(biāo)和中長期發(fā)展規(guī)劃...................................................155四、人力資源管理.......................................................................................................................................156五、信息與圖書管理...................................................................................................................................159六、財務(wù)與價格管理...................................................................................................................................162七、醫(yī)德醫(yī)風(fēng)管理.......................................................................................................................................166八、后勤保障管理.......................................................................................................................................168九、醫(yī)學(xué)裝備管理.......................................................................................................................................173十、院務(wù)公開管理............................................................................