上海市40家医疗机构放射防护管理状况调查  

Radiological Protection Management Levels of 40 Medical Institutions in Shanghai

作　　者：陈春晖[1] 曹国妹 班婷婷 胡兴华 黄伟栋 邵迎辉 沈伟 

机构地区：[1]上海市卫生局卫生监督所,上海200031 [2]浦东新区卫生局卫生监督所,上海200136 [3]静安区卫生局卫生监督所,上海200041 [4]嘉定区卫生局卫生监督所,上海201800 [5]闵行区卫生局卫生监督所,上海201199 [6]黄浦区卫生局卫生监督所,上海200011 [7]青浦区卫生局卫生监督所,上海201700

出　　处：《环境与职业医学》2015年第7期663-666,共4页Journal of Environmental and Occupational Medicine

基　　金：上海市卫生和计划生育委员会课题(编号:20124390)

摘　　要：[目的]了解上海市医疗机构放射防护管理组织和制度的建立及运行状况,以便发现问题,提出有效的干预措施。[方法]选取上海市二、三级医疗机构40家,采用自行设计的调查表,对医疗机构放射防护管理组织和制度的建立及运行情况进行现场调查。[结果]40家医疗机构均设立了放射防护管理组织,65.0%(26家)放射防护管理组织和人员职责分工明确,82.5%(33家)对本机构放射工作部门定期检查,仅25.0%(10家)定期组织放射事件应急演练。40家医疗机构均制订了放射防护管理制度,80.0%(32家)放射防护管理制度符合国家法律法规和标准,仅22.5%(9家)医疗机构对制订程序做出了书面规定,75.0%(30家)放射防护管理制度有相应的落实措施。40家医疗机构均制订了质量保证方案,75.0%(30家)质量保证方案包含了质量管理的全过程,80.0%(32家)具有可操作性并符合机构实际,95.0%(38家)有实施记录且真实可信。[结论]上海市二、三级医疗机构放射防护管理组织和制度设置尚需完善,应进一步开展管理体系研究,引导医疗机构进一步提高放射诊疗安全防护和质量管理水平。[Objective] To understand the establishment and operation of radiological protection management organizations and regulations in medical institutions in Shanghai, so as to identify underlying problems and provide intervention measures. [Methods] A field inspection using self-designed questionnaires was conducted in 40 secondary and tertiary medical institutions in Shanghai. The survey focused on the establishment and operation of radiological protection management organizations and rules. [Results] The selected 40 medical institutions all installed radiological protection management organizations, 65.0%（n=26） of them provided specific job assignments, 82.5%（n=33） performed regular radiological auditing, and only 25.0%（n=10） organized regular radiological emergency drills. All the medical institutions presented radiological protection management rules, 80.0%（n=32） had rules complied with relevant national laws and standards, only 22.5%（n=9） privded written operating procedures for the rules, and 75.0%（n=30） were supplemented by action plans. All the medical institutions developed quality assurance（QA） programs, 75.0%（n=30） of the institutions had QA programs covering the whole process of quality management, 80.0%（n=32） were operational and matched with the institutions＇ capacity, and 95.0%（n=38） provided authentic QA records. [Conclusion] Potential improvement can be made to the existing radiological protection management organizations and rules in secondary and tertiary medical institutions in Shanghai by expanding research on management system in order to promote higher levels of radiological safety protection and service quality management in medical insitutions.

关 键 词：医疗机构 放射防护管理组织 制度 放射诊疗 质量保证方案 放射卫生档案 

分 类 号：R146[医药卫生—公共卫生与预防医学]