【正文】 ............................ 6 第五章 全院員工要重點記憶的內(nèi)容 .............................................................................................................. 6 一、醫(yī)院文化與醫(yī)院管理 ....................................................................................................................... 6 （一）醫(yī)院文化 .............................................................................................................................. 6 （二）醫(yī)院管理 .............................................................................................................................. 7 二、患者安全目標 ................................................................................................................................. 9 （一）嚴格執(zhí)行查對制度 ................................................................................................................ 9 （二）嚴格執(zhí)行醫(yī)囑 ..................................................................................................................... 10 （三）嚴格執(zhí)行手術(shù)安全檢查 ....................................................................................................... 11 （四）嚴格執(zhí)行手衛(wèi)生規(guī)定 .......................................................................................................... 12 （五）規(guī)范特殊藥物管理 .............................................................................................................. 12 （六）臨床“危急值”管理 .......................................................................................................... 12 （七）患者意外事件防范管理 ....................................................................................................... 13 （八）患者壓瘡防范管理 .............................................................................................................. 14 三甲醫(yī)院評審應知應會 2 （九）醫(yī)療安全（不良）事件報告管理 ......................................................................................... 14 （十）鼓勵患者參與醫(yī)療安全 ....................................................................................................... 15 三、重要應急處理 ............................................................................................................................... 15 （一）消防安全與火災應急處理 ................................................................................................... 15 （二）停電應急處理 ..................................................................................................................... 16 （三）氧氣故障應急處理 .............................................................................................................. 16 （四）停水應急處理 ..................................................................................................................... 16 （五）信息系統(tǒng)故障應急處理 ....................................................................................................... 17 （六）大規(guī)模傷員應急處理流程圖 ................................................................................................ 18 四、各部門重點內(nèi)容 ............................................................................................................................ 19 （一）質(zhì)量管理辦公室重要事項 ................................................................................................... 19 （二）醫(yī)務(wù)科重要事項 ................................................................................................................. 19 （三）院感知識 ............................................................................................................................ 26 （四）護理部重要事項 ................................................................................................................. 29 （五）醫(yī)保辦重要事項 ................................................................................................................. 33 （六）門診辦公室重要事項 .......................................................................................................... 34 （七）科教科重要事項 ................................................................................................................. 36 （八）設(shè)備科重要事項 ................................................................................................................. 41 五、檢查重要事項 ............................................................................................................................... 43 （一）模擬三級查房： ................................................................................................................. 43 （二）模