1. Pediatric nosocomial infection self-examination report
In accordance with the spirit of the instructions from the higher level, in-depth implementation of the "Hospital Infection Management Measures" to seriously find the health care institutions in the management of nosocomial infections, the report and disposal of problems, and to further strengthen the management of hospital infections, effective prevention and control of infectious disease pathogens, drug-resistant bacteria, conditional Effective prevention and control of infectious disease pathogens, drug-resistant bacteria, conditioned bacteria and other pathogenic microorganisms of hospital infections and healthcare-acquired infections, enhance the ability of hospitals to prevent and control, to protect the people's health and life safety. Hospital leadership attaches great importance to the president of the personal organization, grasp the implementation, from the establishment of the organization, improve the system, responsibilities, to the first line of supervision, focus, parts, measures, comprehensive norms and science to carry out the management of hospital-acquired infections, self-examination and self-correction work.
First, strengthen the organization and leadership to ensure the smooth implementation of the management of hospital infection.
Our hospital set up a nosocomial infection management team, headed by a dean of the hospital sensory group is responsible for the hospital's control work, and guidance to the lower level departments. Seriously grasp the day-to-day work, regular and irregular supervision and inspection of the nosocomial infection control work of each department, the collection of relevant data on the whole hospital, statistics, and report to the hospital's leading group. Each clinical department has a person in charge of the monitoring work of his/her department and reports the relevant situation to the hospital infection team on time. As a result of the implementation of the work at all levels, to ensure the smooth implementation of our hospital infection management.
Second, seriously carry out self-examination and self-correction
Through a few days of self-examination we still have a lot of problems:
(1) staff knowledge of nosocomial infections and control of awareness is shallow.
(2) Some departments are not fully equipped with disinfection hardware.
(3) Nosocomial infection control system is not comprehensive.
(4) The details of nosocomial infection control are not enough.
(5) Incomplete registration of nosocomial infection.
In response to the problems of our hospital hospital infection management team to analyze one by one, think of ways to find measures to solve the practical problems:
(1) the establishment of an organization to clarify the duties and responsibilities to the person.
(2) sound and improve the system to restrain people.
(3) Installation of ultraviolet lamps, configuration of disinfectant and so on.
(4) the development of nosocomial infection training program to improve the ideological awareness of the staff.
(5) Carry out indoor and outdoor hygiene cleaning.
(6) Do a good job of registration of activities related to nosocomial infections.
Third, further improve the management system and implement
Hospital infection management system is the foundation and important guarantee of good hospital infection. The development of a set of scientific and practical management system, improve the management of hospital infection, disinfection and isolation of various departments, hospital infection report, critical emergency death case discussion, referral of special cases, sewage disposal and other systems. To regulate the behavior of hospital personnel. Strengthen the construction and study of the system, and conscientiously carry out the implementation of the system is extremely important to improve the awareness of prevention and reduce the incidence of hospital-acquired infections. Give full play to the constraints of the system, so that the implementation of the work in practice.
Fourth, strengthened the disinfection room disinfection management.
The hospital leadership attaches great importance to the construction of the disinfection room, in order to improve the disinfection conditions, in the case of hospital funds are tight, and the purchase of a high-pressure steam sterilizer. Logistics Section often check the indoor walls, ceilings, keep smooth, no cracks, no dust. Sterilization room arrangement is reasonable, adhere to the "three zones", "three points". The three zones: contaminated area, clean area, sterile area.
Three open: dirt recycling and release of clean materials separately.
Separate the initial washing and fine washing.
Unsterilized and sterilized items are separated.
In the pressure steam sterilization, adhere to the use of indication tape outside the package, the use of indication cards inside the package for self-monitoring, to ensure the quality of disinfection and sterilization.
V. Continue to grasp the clinical departments disinfection isolation, infection monitoring.
1, according to the "Prevention and Control of Infectious Diseases Act", "Disinfection Management Measures", "the provisions of nosocomial infection", the hospital has strengthened the disinfection isolation of clinical departments, infection monitoring work. Inspections are carried out once every half a month, and the 'problems found are dealt with in a timely manner. When infectious patients are found, the outbreaks are registered and reported in a timely manner. Toxic, harmful and infectious sewage filth must be sterilized. In addition to checking reusable items for sterilization in strict accordance with the requirements, the use of single-use sterile medical supplies has been increased, greatly reducing the possibility of nosocomial infections. In the year's disinfectant replacement and instrument soaking inspection, in addition to some departments occasionally omitted records or incomplete records, instrument soaking and disinfectant preparation, replacement time are in line with the requirements.
2, the monitoring of clinical departments nursing staff's hand surfaces, object surfaces, air, disinfectant, ultraviolet light intensity, autoclave sterilization kit.
3, the hospital leadership team to the department every day to find out whether there are cases of nosocomial infection, there is no omission, misreporting, etc.. Each section of the discovery of nosocomial infection cases, timely registration and reported to the hospital office, and the corresponding treatment.
4, the hospital should seriously improve environmental hygiene, indoor hygiene, personal hygiene and dietary hygiene, and strengthen the hygiene of the patient's publicity and education, to create a clean, quiet, comfortable and safe medical environment for patients.
Sixth, the management of disposable supplies to ensure the medical safety of patients and prevent social pollution.
In this year's purchase of disposable supplies, the hospital leadership to strengthen the management of this area, strict verification, check the quality. The hospital leadership and warehouse custody is responsible for the purchase of disposable supplies for inspection, registration, good disposable supplies, disinfection of medicine and equipment purchased at the gate, to prevent unqualified products into our hospital. In the current year, none of the disposable products purchased by the hospital were unqualified. We have strengthened the storage management of single-use sterile medical supplies, and stored them off the ground and away from the wall according to the requirements. The hospital conducts quarterly inspections of single-use sterile medical supplies stored in warehouses and departments, and the nursing staff strictly checks them before use to prevent expired and invalid single-use supplies from being used by patients. As a result of strict control, there is not a single case of patients using unqualified sterile single-use medical supplies. For the used disposables, each department has been insisting on disfiguring, sterilizing and recording, and the individual not disfigured phenomenon found in the spot check was severely criticized and immediately made up. Therefore, the hospital's disposable empty needles, infusion sets, urine bags, etc. disfigurement, sterilization rate of 100%.
Seventh, strengthen the knowledge of hospital infection training, improve the hospital staff to control the awareness of nosocomial infection.
Combined with the actual hospital, the Hospital Infection Committee has organized lectures and academic exchanges on the prevention of nosocomial infections, such as medical malpractice regulations, disinfection, safety training, blood transfusion related laws and regulations and blood transfusion knowledge learning, etc., the hospital's medical staff for the prevention and control of hospital infections related to knowledge training, to enhance the awareness of the prevention and control of hospital infections. Improve the level of prevention and control of hospital infection in our hospital. However, due to the late start of our hospital's hospital infection control work, there are still deficiencies, such as the diagnosis of hospital infection cases, reporting, statistics and other aspects of the diagnosis is not in place, to be continuously improved and enhanced in the future. We believe that as long as we continue to summarize the experience, learning, we will do a better job of nosocomial infection control.
2. Pediatrics hospital infection self-inspection report
According to the higher issued "on the special inspection of hospital infection management notice" related to the contents of the hospital organization of the staff of the above work carried out a serious self-inspection, is now summarized and reported as follows:
a. Strengthening of the organizational leadership, and further implementation of the "hospital infection
I set up a hospital infection management committee headed by the president, improve the hospital infection management system, the development of all levels of hospital infection monitoring personnel duties, clear responsibilities. The Hospital Infectious Disease Section is responsible for the hospital's infection control work, and timely and correct guidance to the relevant work of the department, and conscientiously grasp the day-to-day work of infection control. Regular or irregular organization of the departments of the sense of control work supervision and inspection, emphasize the duties of the departments of the sense of control group, strengthen the sense of control group members of the training, regular inspection of the relevant systems, norms of the implementation of the situation, so that the departments on the sense of the importance of the work of the sense of control of the understanding of the gradual enhancement.
Second, according to the requirements of hospital infection management, do a good job of infection monitoring.
Strengthen the study of disinfection and isolation system and aseptic operation techniques, strict compliance with disinfection and isolation and aseptic technical procedures. UV lamp disinfection registration specific to each lamp, accurate registration of disinfection hours, replacement time, weekly 95% alcohol wipe time, every six months to test the irradiation intensity of UV lamps, to ensure the effectiveness of disinfection, and make a detailed record.
Third, combined with antibacterial drug special treatment work and "three good and one satisfaction" activities to strengthen cooperation between departments and the use of antibacterial drugs management, in accordance with the "clinical application of antibacterial drugs special remediation activities of the work program" of the medical staff to carry out full training, by the vice president of the Huang Jubin monthly access to outpatient prescriptions, inpatient records, detailed understanding of the application of antibacterial drugs in the hospital, and to ensure that the hospital's medical staff is not only the best in the field of antibacterial drugs, but also the most effective. The hospital has a detailed understanding of the application of antimicrobial drugs, unreasonable use of medication, unreasonable prescriptions to be warned, punished.
Fourth, to strengthen the management of disinfection medicine, disposable sterile goods. The warehouse strictly check whether the documents of the purchased products are complete, whether the packaging and quality of the pass, to keep a good gate, after the purchase of the relevant items in accordance with the requirements of the storage and management. Strictly prevent the use of unqualified disinfection products, disposable sterile goods to patients to ensure medical safety.
Fifth, to strengthen the hospital infection management knowledge training, improve the awareness of medical staff hospital infection, so that the clinical medical staff spontaneously involved in hospital infection management. Clinicians and nurses are trained at different levels and with different contents, so that everyone understands the key contents they must master.
Sixth, the conscientious implementation of the "Medical Waste Management Regulations", clear responsibilities of all types of personnel to strengthen the management of medical waste and regular supervision and inspection. Requirements for each department in strict accordance with the medical waste classification catalog for collection, categorization, strictly prohibit the mixing of medical waste and domestic waste. Medical waste is collected and transported to the temporary storage point to avoid leakage, loss and other undesirable situations.
VII. Strengthen the management of occupational exposure of medical staff to protect the safety of employees. Strengthen the training of medical staff knowledge of occupational exposure, standardize the disposal process of sharp instruments, requiring each person to master the process of handling sharp instrumental injuries, to minimize the harm caused by occupational exposure. The personnel who have had occupational exposure according to the type of exposure source for tracking and monitoring and guidance to ensure the safety of medical staff.
VIII.
Department of medical staff hospital infection awareness still needs to be strengthened, the relevant knowledge is still lacking, hand hygiene implementation needs to be further enhanced, some medical staff on the treatment process after occupational exposure is not enough to grasp, disinfection and isolation measures, some of the details still need to be strengthened; has not been able to carry out bacterial culture and monitoring as well as hospital-acquired diseases or suspected cases of supervision; not equipped with a medical waste incinerator, the focus of the The layout and flow of the department need to be further standardized. Hospital sewage system management needs to be strengthened.
IX, corrective measures.
1 according to the plan for the medical staff to carry out training in hospital sensory knowledge, familiar with the process of handling occupational exposure.
2 send people to higher hospitals for further training, and strive to carry out the necessary failure to carry out the training and monitoring up.
3 apply for the installation of medical waste incinerator.
4 Strengthen the management of the hospital sewage system.