护理_临床护理_核心制度_应急处置预案教（学）案程序文件

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1、........目录第一章临床护理核心制度···············（一）护理质量管理制度······················（二）术前患者访视制度······················（三）病房管理制度··························（四）抢救工作制度··························（五）护理不良事件报告制度··················（六）护理安全管理制度······················（七）分级护理制度·················

2、·········（八）病房一般消毒隔离管理制度··············（九）护理会诊制度··························（十）护理交接班制度························（十一）查对制度······························（十二）患者健康教育制度······················（十三）护理查房制度··························（十四）给药制度······························（十五）患者身份识

3、别制度与程序················（十六）医嘱制度与执行流程····················第三章应急预案及程序·················（一）停水和突然停水的应急院预案及程序······已讲（二）泛水的应急预案及程序··················已讲（三）停电和突然停电的应急预案及程序········已讲（四）失窃的应急预案及程序··················已讲（五）住院患者出现输液、输血反应的应急预案及程序································已讲.

4、专业学习资料.........（六）患者发生空气栓塞的应急预案及程序······已讲（七）急性消化道大出血患者的应急预案········已讲（八）创伤性休克的应急预案及程序············（十）子痫的应急预案························不讲（十一）羊水栓塞的应急预案····················不讲（十二）火灾的应急程序························已讲（十三）地震的应急程序························（十四）患者坠床/摔倒时的应急程序····

5、·········已讲（十五）有毒气体泄漏的应急程序················（十六）患者发生化疗药外渗时的应急程序········不讲（十七）患者发生躁动时的应急预案及程序········（十八）急性心包填塞的应急预案················不讲（十九）脂肪栓塞综合征应急预案················不讲（二十）急腹症应急预案························(二十一)窒息的应急预案························（二十二）误吸的应急预案···············

6、·········（二十四）患者外出不归的应急预案················已讲（二十五）休克的应急预案及程序···················（二十六）脑疝患者的应急预案及程序···············不讲（二十七）突然发生猝死应急预案及程序·············已讲（二十八）患者自杀的应急预案及程序···············已讲　第一章　临床护理核心制（一）护理质量管理制度一、医生成立由分管院长、护理部主任、护士长组成的护理质量管理委员会，负责全院护理质量管理目标及各项护理质量标准的制定并对护

7、理质量实施与管理。二、护理质量实行护理部、病区二级控制与管理。1、病区护理质量控制组：（Ⅰ.专业学习资料.........级）由2-3人组成，病区护士长参加并负责，按照护理质量标准对护理质量实施全面控制，及时发现工作中的问题与不足，对出现的质量缺陷进行分析，制定改进措施。检查有记录、登记并及时反馈，每月填写检查登记表及护理质量月报表上报护理部。2、护理部护理质量控制组，（Ⅱ级）由8-10人组成，护理部主任参加并负责。每月按照护理控制项目有计划、有目的、有针对性的对各病区护理工作进行检查评价，填写检查登记表及综合报表。及

8、时研究、分析、解决、检查中发现问题。每月在护士长会议上反馈检查结果，提出整改意见，限期整改。三、各科建立护理文书终末质量控制小组，由各种护士长及责任护士负责。每月对新入院、出院患者的护理文件及医嘱等进行检查评价，填写检查登记表上报护理部。四、对护理质量缺陷进行跟踪监控，实现护理质量的持续改进。五、各级质控组每月按时上报检查结果，科