年年终医疗质量与安全结果评价、分析与改进活动医疗质量与安全管理小组活动记录活动日期：年月日活动地点：主持人：科主任记录人：参加人员：一、科室主要业务指标分析与改进措施（一）年各月科室主要业务指标完成月指标份监测指标项目一月二月三月四月五月六月七月八月九月十月十一月十二月门诊人次200180250195180230出院人数（人）6710111098101110门诊手术人数（人）654855704860住院手术人数（人）603560653555病床使用率（%）9610511098105110床位周转次数101515141316平均住院日（天）14.013.012.512.812.612.5门诊患者人均费用（百元）200240235230220235住院患者人均费用（千元）9.58.68.58.27.98.5020406080100120140160180200220240260一月二月三月四月五月六月七月八月九月十月十一月十二月全年各月科室主要业务指标情况表1180250195180230671011101019610512098105110200240235230220235654855704860603560653555门诊人次出院例数病床使用率(%)门诊患者人均费用（百元）门诊手术例数住院手术例数02468101214161820一月二月三月四月五月六月七月八月九月十月十一月十二月全年各月科室主要业务指标情况表210151514131614.013.012.512.812.612.59.58.68.58.27.98.5床位周转次数平均住院日住院患者人均费用(千元)（二）对以上指标进行评价：（三）评估（分析）原因：（四）改进措施：二、医疗质量管理分析与改进（一）全年各月医疗质量主要完成情况监测月指标份监测指标项目一月二月三月四月五月六月七月八月九月十月十一月十二月住院患者死亡率（%）5.0%4.0%3.5%2.5%2.0%1.0%5.0%4.0%3.5%2.5%2.0%1.0%2周内再住院率（%）2.0%3.0%1.5%1.0%0.5%0.0%2.0%3.0%1.5%1.0%0.5%0.0%1月内再住院率（%）3.0%3.5%2.5%2.0%2.3%0.0%3.0%3.5%2.5%2.0%2.3%0.0%非预期再次手术率（%）2.5%2.0%1.0%3.0%0.0%0.0%2.5%2.0%1.0%3.0%0.0%0.0%住院超过30天患者人数（人）手术死亡率（%）5.0%4.2%3.0%2.0%1.0%1%5.0%4.2%3.0%2.0%1.0%1%临床路径完成率（%）80.0%85.0%90.0%95.0%96.0%97.0%80.0%85.0%90.0%95.0%96.0%97.0%单病种平均住院日181716.517.51716181716.517.51716抢救成功率（%）96.0%98.0%98.5%98.5%97.0%97.0%96.0%98.0%98.5%98.5%97.0%97.0%主要诊断与病理诊断符合率（%）100.0%100.0%100.0%100.0%98.0%100.0%100.0%100.0%100.0%100.0%98.0%100.0%输血人数输血总人次（200ml/次）一次输血≥2000ml（例数）门诊处方合格率94.0%95.0%96.5%94.0%97.0%96.0%94.0%95.0%96.5%94.0%97.0%96.0%甲级病案合格率96.0%98.0%97.0%95.0%96.0%96.5%96.0%98.0%97.0%95.0%96.0%96.5%0.0%1.0%2.0%3.0%4.0%5.0%一月二月三月四月五月六月七月八月九月十月十一月十二月全年各月科室医疗质量主要监测指标表12.0%3.0%1.5%1.0%0.5%2.0%3.0%1.5%1.0%0.5%3.0%3.5%2.5%2.0%2.3%3.0%3.5%2.5%2.0%2.3%2.5%2.0%1.0%3.0%0.0%0.0%2.5%2.0%1.0%3.0%0.0%0.0%2周内再住院率1月内再住院率非预期再次手术率0.0%1.0%2.0%3.0%4.0%5.0%一月二月三月四月五月六月七月八月九月十月十一月十二月全年各月科室医疗质量主要监测指标表24.5%4.0%3.5%2.5%2.0%4.5%4.0%3.5%2.5%2.0%5.0%4.2%3.0%2.0%1.0%1.0%5.0%4.2%3.0%2.0%1.0%1.0%住院患者死亡率手术死亡率75.0%80.0%85.0%90.0%95.0%100.0%105.0%110.0%一月二月三月四月五月六月七月八月九月十月十一月十二月全年各月科室医疗质量主要监测指标表380.0%85.0%90.0%95.00%96.00%80.0%85.0%90.0%95.00%96.00%96.0%98.0%98.5%98.50%97.00%97.00%96.0%98.0%98.5%98.50%97.00%97.00%临床路径完成率抢救成功率90.0%92.0%94.0%96.0%98.0%100.0%102.0%104.0%一月二月三月四月五月六月七月八月九月十月十一月十二月全年各月科室医疗质量主要监测指标表4100.0%100.0%100.0%100.00%98.00%100.00%100.0%100.0%100.0%100.00%98.00%100.00%主要诊断与病理诊断符合率90%92%94%96%98%100%一月二月三月四月五月六月七月八月九月十月十一月十二月全年各月科室医疗质量主要监测指标表594%95.0%96.5%94%97.00%96.00%94%95.0%96.5%94%97.00%96.00%95%95%95%95%95%95%95%95%95%95%96.0%98.0%97.0%95%96.00%96.50...
