Letter of the general office of the National Health Commission on notifying Wenshui County People's Hospital of relevant events
Health committees of all provinces, autonomous regions, municipalities directly under the central government and Xinjiang production and Construction Corps:
On July 18, 2019, after the media exposure of the incident of "the elderly in critical condition asking for help but the doctor is taking pictures" in Shanxi Wenshui County People's Hospital, our committee attached great importance to it and immediately instructed Shanxi Provincial Health Committee to carefully verify the truth of the incident, properly comfort the family members and seriously deal with the relevant responsible persons. The investigation found that the incident was caused by the medical staff's indifferent concept of "patient-centered", weak awareness of quality and safety, and weak awareness of risk prevention. The nature of the incident was bad, resulting in adverse social impact and damaging the overall image of the medical industry. The relevant information is hereby notified as follows:
1、 Basic information of the event
On the evening of July 14, an elderly female patient in Wenshui County People's Hospital of Shanxi Province was admitted to the hospital because of 'toothache for several days, upper abdominal discomfort, nausea and vomiting for two days and arrhythmia', and was admitted to the Department of Cardiology in the emergency department. The admission diagnosis was arrhythmia, paroxysmal atrial tachycardia, cardiac insufficiency, etc. corresponding treatment was given, relevant examinations were improved, and a critical notice was issued. On the morning of July 15, when the patient's condition worsened and needed emergency treatment, the Department of Cardiology took collective photos to make the Department profile brochure, and failed to check the patient in the ward in time. After verification by the health administrative departments of Shanxi Province, Luliang City and Wenshui County, the situation is basically consistent with the media reports. The incident exposed a series of problems, such as omissions in the management of the local health administrative department and Wenshui County People's Hospital, weak awareness of medical quality and safety of medical personnel, weak awareness of medical risk prevention, and inadequate education and training of medical ethics.
（1） Problems in Wenshui people's hospital.
1. The hospital's concept of "patient-centered" is indifferent, and the construction of medical ethics is not in place. During the expansion of scale and the development of discipline construction, the hospital played down the medical ethics education for medical staff, resulting in that when there were critically ill patients in the ward, the departments were taking collective photos, and the doctors on duty were not arranged to deal with emergencies. Medical staff are indifferent when the patient's family members reflect their condition, which violates the service concept of 'patient-centered'. In addition, the hospital arranged to take photos on Monday morning when patients are more concentrated, which also reflects the hospital's indifference to the concept of "patient-centered".
2. The awareness of medical quality and safety is not strong, and the core system of medical quality and safety is not implemented. The hospital failed to learn, train and understand the core system. During the group photos taken by the Department, the patient's family members reported the condition to the medical staff in the Department of Cardiology, but the medical staff did not pay attention to it, did not check the patients in the ward in time, and failed to implement the core medical quality and safety systems such as the first diagnosis responsibility system, the duty and shift system, the rescue system for acute and critical patients, and the graded nursing system, The inadequate management of critically ill patients highlights the serious problems in their awareness of medical quality and safety.
3. The daily management of the hospital needs to be strengthened. The management did not manage people according to the system. After this incident, the relevant responsible persons were not dealt with in accordance with the law and regulations immediately, and there were obvious management loopholes.
（2） Problems existing in health administrative departments. Wenshui County Health and Sports Bureau's ideological position is not high, its political sensitivity is not strong, it does not pay enough attention to and pay enough attention to network public opinion, and it fails to perform its management functions in time. The ability to deal with risks and emergencies is insufficient. After the event, it did not report to the superior competent department at the first time, so it has unshirkable responsibility in the continuous expansion of the situation. The medical institutions under the jurisdiction were poorly supervised, the daily inspection and supervision were not in place, and the long-standing management loopholes and problems of Wenshui County People's hospital were not found in time.
2、 Event handling results
Shanxi Province has instructed Wenshui County to seriously deal with the relevant responsible persons in accordance with the regulations on disciplinary measures of the Communist Party of China and the Interim Provisions on disciplinary measures for staff of public institutions:
Order Yang Fengming, deputy head in charge of Wenshui County, to make a written inspection; Admonished Zhang Guoqiang, director of the health and Sports Bureau of Wenshui County; Ma Yongsheng, head of the medical administration and medical management unit of the health, health and Sports Bureau of Wenshui County, was given an inner-party warning.
Li Haiyun, Secretary of the Party branch and President of Wenshui County People's Hospital, was given a serious warning within the party; Give Zhang Zhijian, vice president, inner-party warning; Guo Shijun, director of medical department, was given demerit recording punishment; Wu Xiaoying, deputy director of the office, Li Jingkai, director of Cardiology, and Carina Lau, head nurse of Cardiology, were dismissed; Give administrative sanctions to Li Hongyan, the attending physician of Cardiology Department, and he Xuejiao, the responsible nurse, to suspend their practice activities for one year; Sun Yanmei, a cardiologist, was given an administrative warning.
At the same time, Shanxi Provincial Health Commission has instructed relevant departments to strengthen comfort and condolences to the patients' families, and will coordinate and solve the compensation problem through the provincial medical adjustment Commission.
3、 Next work requirements
Local health administrative departments at all levels and various medical institutions at all levels should fully learn the lessons of this incident, draw lessons from one example, firmly establish the service concept of "patient-centered", improve the quality of medical services, strengthen risk prevention awareness, strengthen medical ethics education and work style construction, and ensure medical quality and patient safety.
（1） Combined with theme education, strengthen the concept of serving the people. Health administrative departments at all levels and all kinds of medical institutions at all levels should, in combination with the theme education of "never forget the original heart and remember the mission", strengthen the Humanistic Construction of hospitals, vigorously carry forward the noble spirit of "protecting life, saving the dead and healing the wounded, being willing to contribute and loving the boundless", educate medical personnel to stick to the original heart of serving the people's health and shoulder the mission of protecting the people's health.
（2） We will strengthen education in medical ethics and work style, and rectify work style and discipline. All kinds of medical institutions at all levels should 'warn by case', carry out medical ethics warning education, find internal management loopholes, further strengthen the service concept of 'patient-centered', and effectively solve the outstanding problems existing in the work style of medical personnel. We will rectify the behaviors that violate the professionalism, the routine of diagnosis and treatment, and the core system of medical quality and safety, and establish a good image of the health industry.
（3） Improve the quality of medical services and strengthen the awareness of risk prevention. All kinds of medical institutions at all levels should stand at the height of safeguarding the people's health rights and interests, strengthen learning, education and training, organize cause analysis of risk points, build a risk prevention and control system, optimize processes and standardize management, improve the quality of medical services, adhere to the bottom line of quality and safety, comprehensively strengthen risk prevention awareness, and ensure medical quality and patient safety.