Hospital infection work summary essay (selected 5)
Time flies, a period of time has come to an end of the work, looking back on the strong through this period of time, the achievements are hard-won, we have to do a good job of reviewing and sorting out, write a good summary of the work of the oh. Then how to write it? The following is my compilation of hospital infection work summary sample (selected 5), for reference only, we take a look at it.
Hospital infection work summary 1
Hospital infection monitoring:
xxx year internal medicine *** counted xxx patients discharged, the number of nosocomial infections occurred xx people, the infection rate of 1.98%, the number of cases of infection was 43 cases, no hospital infection late report, underreporting of cases. The sites of nosocomial infections were 4 cases of upper respiratory tract, 36 cases of lower respiratory tract, 2 cases of urinary tract infections, and 1 case of catheter-related infection. Comprehensive infection factors are considered as: cerebral infarction patients are old, long-term bedridden, elderly patients, low body resistance, there is a high risk of infection. According to the characteristics of patients and diseases admitted to our department, more than 90% of patients with hospital-acquired infections are patients with strokes and many basic diseases in the elderly, and the reasons for this are: patients with hospital-acquired infections are mostly elderly, with many basic diseases, heavy condition and long duration of disease, and due to poor physical condition, poor nutrition and weakened or disappeared of the normal reflexes of swallowing and coughing in different degrees, the function of expectoration decreases, and the phlegm is not easily coughed out in the bedridden patients, and catheterization is not easy. The fall is not easy to cough up, catheterization invasive operation and other factors, in view of the characteristics of our department, our medical staff seriously standardize all kinds of medical operations, nursing work seriously and responsibly, to encourage and help patients to turn over to promote the discharge of sputum, oral cleansing, catheterization and sleep on the anti-decubitus air mattress beds and other nursing care, are effective in reducing the incidence of intra-hospital infections in the Department of.
Second, the strict implementation of the "disinfection and isolation system", to strengthen the management of sterilized items, disposable sanitary supplies, disinfectants, and strengthen the environmental management, the Department of Hospital Sense Group regular self-inspection of the Department, found that the problem of timely rectification, and timely summary records.
Third, with the sense of control section under the department of a variety of testing and inspection work, for the inspection of the problems found in the feedback situation and then repeated serious study and summarize the record. *** with the efforts to effectively control the hospital infection.
Fourth, pay attention to the knowledge of hospital infection education and training work, the whole staff adhere to the quarterly centralized study of hospital infection-related knowledge, and actively participate in the hospital infection knowledge lectures and training. Enhance the sense of responsibility of the department staff of hospital infection.
Fifth, standardize the management of medical waste: standardize the management of medical waste in my department, no medical waste irregularities, no loss of medical waste.
Sixth, occupational exposure work: the importance of occupational exposure prevention and control of disposal of standardized procedures for the study, to enhance the self-protection awareness of the department's medical staff, the year no medical staff occupational exposure events.
seventh, pay attention to bacterial drug resistance monitoring and multi-drug resistant bacteria monitoring, will be included in the department's "critical value" management, organization of the department staff to learn a variety of multi-drug-resistant bacteria prevention and control measures, and according to the Department of a "multi-drug-resistant bacteria infection" case, to carry out practical exercises. The case, to carry out combat drills, timely isolation of patients, according to the requirements of the contact isolation labeling, and the department staff, cleaning staff to carry out multi-drug-resistant bacteria prevention and control measures for the training of family members also carried out some disinfection and isolation knowledge of the training of the effective prevention of the occurrence of hospital infections.
Eight, seriously organized learning hand hygiene norms. And the whole department assessment, hand hygiene compliance comparison has improved.
Existing deficiencies:
1, part of the staff hand hygiene compliance is low, there are a small number of daily work did not wash their hands according to the indications of the phenomenon;
2, occasional sometimes workers appear to be disinfectant opened without labeling the phenomenon of the opening time;
3, occasional treatment room cleaning is not in place, the lighting accumulates dust, air conditioning vents have cobwebs, etc.
3, occasional treatment room cleaning is not in place, lighting accumulation dust. The air conditioning vents have cobwebs and other phenomena.
4, hospital infection cases reported card is not recorded in a timely manner to the "hospital infection management manual" in the "monthly hospital infection case registry".
5, individual months, "Hospital Sickness Management Manual" found in the problem, the department has done to rectify and improve, but did not record the section of self-examination, analysis of the causes of the problem and corrective measures.
6, the second A ledger "sense of hospital" part of the record is not completed in a timely manner. The company's website is a good place to find out more about the company's services.
For the above problems I will continue to pay great attention to the Department, seriously to rectify.
The hospital infection work summary 2
20xx in the dean and the hospital party committee attaches great importance to the correct guidance of the hospital infection management committee, all for the first line of service of the ideology, in the hospital under the close cooperation of the various departments, in the whole health care workers **** with the efforts of the hospital infection work has made certain achievements, is now to the hospital leadership to report:
First, in accordance with the hospital The party committee at the beginning of the year to develop the focus of the work, seriously implement the spirit of the relevant provincial and municipal documents, to strengthen the learning of medical ethics, to comply with the rules and regulations of the hospital, and actively participate in the activities organized by the hospital, the department of political learning, business learning once a month, and have a record.
Second, the adjustment of the organization and the improvement of the system. According to some personnel changes and work needs, re-adjustment of the following five management organization members: that is, the Hospital Infection Management Committee, Infectious Disease Management Committee, Medical Waste Management Committee, the departments of infection management leading group, epidemic leading group. And in the form of documents issued to all relevant departments. According to the relevant national laws, regulations and work requirements to improve the relevant management system. Such as hyperbaric oxygen chamber disinfection isolation system, ventilator and its pipeline oxygen humidification bottle nebulizer and its pipeline cleaning and disinfection system, multi-drug-resistant bacteria infection prevention and control system, medical waste safety management system.
Third, in order to reduce the nurse form record writing time, the Infection Branch redesigned the disinfectant concentration ratio registration form and supervision and inspection record form, so that nurses have more time to serve with patients, but also for the hospital to save expenditure. Three down a send work as always, the treatment area has a variety of report cards, telephone on call, the Infection Branch staff 24 hours a day.
Fourth, in order to do a good job of targeted monitoring of nosocomial infections, quarterly monitoring of the rate of nosocomial infections in the various treatment areas and analysis of the feedback is issued, so that appropriate interventions can be taken in a timely manner. Targeted monitoring began in July. As of the end of October *** access to the number of discharged cases ** cases, the number of cases of nosocomial infection ** cases, the rate of nosocomial infection is 4. 03% (the rate of nosocomial infection in hospitals abroad to study stipulates that ≤ 10%) the rate of omission of 0, the rate of aseptic surgical incision A healing rate of 100%, the qualification rate of aseptic items 100%.
Fifth, strengthened environmental hygiene, disinfection and sterilization effects and hand hygiene monitoring. In order to standardize the hospital's disinfection work and prevent nosocomial infections, the six industry health standards issued by the Ministry of Health were issued to the operating room and supply room. The staff of the Infection Department monitors the intensity of ultraviolet lamps in all departments of the hospital once a quarter, and replaces them in time when they are found to be unqualified, so as to ensure the effect of disinfection. The key departments such as operating rooms, supply rooms and other high-risk areas of the environmental science monitoring has increased the frequency, the pass rate of 100%.
Six, according to our hospital to develop the clinical application of antimicrobial drugs grading management system, the use of antibiotics for those who have crossed the level should be the approval of the superior physician single, quarterly notification of antibiotic use of the whole hospital for the rational use of antibiotics for the clinical departments of physicians to provide a reliable basis.
* year is the hospital up and down the most important year, ** year our hospital accepted to go abroad to study in the provincial health department level hospital review experts review, is the most important year of hospital infection management department, hospital infection is one of the important content of the review of the level of hospitals, through the level of the hospital review to promote the hospital's attention to the work of the hospital infection.
**Year in the hospital leadership attaches great importance to and under the correct leadership, in the hospital departments as well as all the staff's strong assistance, support and cooperation, according to the level of hospital accreditation of the relevant requirements of the Hospital Infection Management Department has completed the following work:
Revise and improve the hospital infection management system, strengthen the knowledge of hospital infection training, regularly convene meetings of the Hospital Infection Management Committee to participate in the design of new and renovated building layouts, participate in the hospital infection management committee meeting. Layout design of new and reconstructed buildings, according to the requirements of hospital infection management, do a good job of case prospective, retrospective and current rate of investigation, and environmental hygiene, disinfection and sterilization effects and hand hygiene monitoring, analysis and feedback, to strengthen the supervision and management of disposable medical supplies, instruments and medicines, and to strengthen the management of medical waste and wastewater. The key work is to strengthen hand hygiene publicity, management of drug-resistant bacteria and management of rational use of antimicrobial drugs, improve the rate of pathogenicity delivery, put forward targeted control measures and guide the implementation of the hospital departments to carry out special inspections of hospital infections, the key departments of hospital infections to carry out key supervision, and constantly increase the focus of the link of quality control and continuous quality improvement, thus effectively preventing and controlling hospital infections `occurring
Now the ** summary of the work specifically reported as follows:
First, improve the hospital infection management organization
(a) re-revised and issued the "on the adjustment of the first affiliated hospital of the College of Medicine abroad hospital infection prevention and control of the three-tier monitoring network notice", and conscientiously implement the "Hospital Infection Management Measures", the hospital infection management committee held regular meetings.
(2) the implementation of clinical departments hospital infection monitoring group, in accordance with the requirements of hospital infection management responsibility, strict implementation of hospital infection related laws and regulations and the implementation of the rules and regulations, give full play to the monitoring of the doctor, monitoring nurses and other health care workers hospital infection management duties, hospital infection management work in place.
Second, revise and improve the management of hospital infections
Special inspection of the hospital's clinical departments, focusing on the inspection of the hospital infection management of key departments, such as ICU, PICU, NICU, RICU, endoscopy, operating room, blood purification centers, central supply room, etc., and early detection of potential safety hazards, early intervention measures to prevent the occurrence of hospital infections. Hospital infection occurs.
The hospital infection prevention and control monitoring of ventilator-associated pneumonia, catheter-associated infections, and blood flow catheter-associated infections in the ICU was carried out.
Three, strengthen the management of drug-resistant bacteria, improve the rate of pathogenetic delivery, guidance for the rational use of antimicrobial drugs
Improve the supervision, monitoring and management of multi-drug-resistant bacteria, the strict implementation of multi-drug-resistant bacteria prevention and control system, the development of multi-departmental joint meeting system, multi-departmental joint management, and regularly provide the clinic with the trend of drug-resistant bacteria report,. Constantly strengthen the supervision and management and implement the system.
Regularly convene multi-drug-resistant bacteria contact meeting, in the multi-drug-resistant bacteria joint meeting, improve the regulatory mechanism, strengthen the multi-departmental collaboration, especially to strengthen the joint management of the medical department, mobilize the enthusiasm of doctors to control bacterial resistance, effective implementation of the bacterial resistance monitoring and early warning mechanism, supervise the key departmental units to complete the statistical analysis of the drug-resistant bacteria, to provide guidance for the rational use of antibacterial drugs for the clinic. Strengthening the management of hospital infections.
In accordance with the "Guiding Principles for the Clinical Application of Antimicrobial Drugs" and "Management Measures for the Implementation of the "Guiding Principles for the Clinical Application of Antimicrobial Drugs" in Anhui Province, etc., to strengthen the pathogenicity of the test, the hospital infection management department of the clinical department of the pathogenicity of the test inspection, through the inspection and publicity, the rate of the pathogenicity of the test to be able to reach 30%.
The hospital infection management department carries out the analysis of bacterial resistance in the whole hospital, and releases it to the "Hospital Infection Monitoring Information", and analyzes the situation of bacterial resistance in the key departments, which provides the basis for the rational use of antimicrobial drugs in the clinic, and analyzes the appropriateness of antimicrobial drugs according to the situation of bacterial resistance.
Fourth, according to the requirements of hospital infection management, do a good job of case prospective, retrospective and current rate of investigation
Clinical department physicians of all hospitalized patients with hospital infection prospective investigation, found that the hospital infection can be timely and accurate report, while the hospital infection department also strengthened the management of hospital infection cases reported to the hospital to strengthen the management of hospital infection cases, monitoring and control, and to the quarterly report to the Hospital Infections Department, to strengthen the hospital infections, and to the hospital infections, to the hospital infections. Monitoring and control, and quarterly to the provincial quality control center for online direct reporting of hospital infection cases.
(a) the hospital regularly carry out comprehensive monitoring, to participate in the * province's current rate of investigation, on the day of the * month * day of the hospital now cases of comprehensive cross-sectional survey, the hospital *** hospitalized * people, the actual survey * people, the acceptance of the survey rate of 100%. The number of hospital-acquired infections * people, the rate of current cases is 1.45%, no hospital-acquired infections underreported.
(2) to carry out two targeted monitoring, real-time monitoring of hospital infections, reduce the incidence of hospital infections in key areas.
(1) in ** from * to * to carry out a class of surgical incision infection of the target monitoring, monitoring object is the hospital oncology surgery surgery of a class of incision of all patients, regular monitoring results back to the clinician, in order to timely analysis of the causes of infection, to take effective preventive and control measures, to reduce the incidence of surgical incision infection, to enhance the health care personnel pay attention to the awareness of hospital infections, and is conducive to the improvement of the quality of medical care, to reduce the patient's hospital infection. It is also conducive to improving the quality of medical care and reducing the pain and economic burden of patients.
(3) carried out multi-drug-resistant bacteria hospital infection target monitoring, the monitoring object is the year all hospitalized patients with bacteriological culture of multi-drug-resistant bacteria, through the monitoring, early discovery of multi-drug-resistant bacteria infected patients, to guide the clinical staff to implement isolation of drug-resistant bacteria precautions, and to remind clinicians in the control of the infection, and then negative bacteriological culture before lifting the quarantine, effective prevention and control of multi-drug-resistant bacteria in the hospital, and to prevent and control the incidence of surgical incision infection. The company also reminds clinicians that the quarantine can be lifted only after the infection is controlled and the bacteriological culture is negative again, so as to effectively prevent and control the spread of multi-drug-resistant bacteria in the hospital and ensure medical safety.
(C) environmental hygiene, disinfection and sterilization effect and hand hygiene monitoring
Hospital Infectious Disease Division of the hospital departments of the treatment room, change room disinfection and sterilization effect of monitoring, and at the same time to strengthen the operating room, gastroscopy, stomatology, supply room, catheterization room and other high-risk areas of the environmental hygiene monitoring and monitoring of the hand hygiene of medical staff. Important collection of air, object surface, hygienic hand, disinfectant, sterile goods, remove air culture has 2 copies failed, other pass rate 100%. Monthly monitoring of discharged sewage, the requirement must meet the standards and then discharged. Quarterly environmental hygiene monitoring of medical waste storage sites.
V. Participate in the design and decoration of the layout of the departments of the new outpatient and emergency building
Participate in the design and decoration of the indoor layout of the new outpatient and emergency building, so that it can comply with the requirements of the control of hospital infections, supervise the installation of air-cleaning and disinfecting equipment, so that the use of the corresponding equipment in line with the requirements of the control of hospital infections, and cooperate with the new outpatient building. In addition to the relocation of the new outpatient building, the company is also working on the environment and disinfection from the perspective of hospital infections.
Six, strengthen the management of medical waste, to ensure environmental safety
Hospital medical waste and sewage disposal in strict accordance with the "Medical Waste Management Regulations" and the health administrative departments on the disposal of medical waste management regulations, requiring recycling personnel and the clinical medical and technical departments to rigorous handover, the two sides to sign, with a double layer of yellow medical waste bags loaded after the The waste will be transported in sealed bags. The accountability system is implemented to avoid the loss of medical waste and ensure medical safety. Requirements for staff equipped with the necessary personal protective equipment, the clinical departments of the classification of medical waste disposal, there are handover registration records, medical waste temporary storage point in line with the requirements, in line with the provisions of the "five preventive", and the strict implementation of cleaning and disinfection measures.
VII, major events rapid response
The system of hospital infection outbreak reporting process and disposal plan, found that the clinical departments have an epidemic trend of infection or a particular pathogen infection and other situations, rapid response, the first time to the scene, change the examination and control of the incident for the intervention in advance, pay close attention to the dynamics of the hospital infection, and take targeted control measures, change the passive control measures, and the first time to the site, and the second time to the site. The first time to arrive at the scene, change after the inspection and control to early intervention, pay close attention to the dynamics of the hospital infection, take targeted control measures, become passive for active, effectively prevent the occurrence of hospital infection, for clinical departments to provide guiding opinions, to control the spread of major events in the hospital.
Inadequate and need to improve:
1, the hospital section of the system is not completely updated in a timely manner, the Hospital Infection Management Division will organize hospital infection experts to carry out hospital infection section of the hospital system inspection, requiring the hospital section of the hospital infection system updated in a timely manner.
2, multi-drug-resistant bacteria joint meeting needs to be held regularly and in a timely manner, the need to further strengthen multi-departmental collaboration, in particular to strengthen the joint management of the Medical Department, to provide guidance for the rational use of antimicrobial drugs for the clinic, and to strengthen the management of hospital infections.
3, the need to further strengthen the supervision and management of single-use medical supplies, and further strengthen the single-use medical supplies and disinfection of medical equipment to ensure compliance with the requirements of hospital infections, to achieve the effect of disinfection and sterilization, and to eliminate the re-use.
4, to further strengthen the key departments, key departments and key aspects of the hospital infection monitoring, such as ventilator-related pneumonia, indwelling catheter-related infections, surgical site infections and dialysis-related infections and other key items of management.
5, the layout of the key departments of the process such as operating rooms, maternity wards partition does not meet the specification requirements, ICU guardianship hall and isolation room lack of mobile water hand-washing facilities, microbiology laboratory dirt disposal room location is unreasonable, etc., the Hospital Infection Management Department needs to be communicated with the General Affairs Department, the Department of Infrastructure to carry out corrective action.
6, the hospital infection management section of the monitoring work needs to be more detailed, more in-depth, to reduce the rate of hospital infection.
7, the doctor hand washing compliance to be further improved.
Summary of hospital infection work 4
With the development of medicine and medical model of change, hospital infection in hospital management occupies an important position. Hospital infection is not only related to the health of doctors and patients and affects the quality of hospital care. Under the attention and concern of the hospital leadership, from the beginning of the implementation of the organization, to the strict management system, to take a variety of measures, so that our hospital infection management is gradually standardized, institutionalized. In order to further improve the management of hospital-acquired infections in the future, the hospital infection control work this year is summarized as follows:
First, strengthen the organizational leadership, to ensure the smooth implementation of hospital-acquired infections management work
The hospital infection management organization consists of three-tiered system, the Hospital Infection Management Committee - Hospital Infection Management ---- Clinical departments hospital infection monitoring group consists of the business dean as chairman, focusing on the monitoring group personnel to supplement and adjust, and clarify the responsibilities of personnel at all levels of the system. All levels of hospital infection monitoring personnel to fulfill the corresponding functions of hospital infection management, thus further improving the management of hospital infection.
Second, according to the plan of education and training to improve the hospital's medical staff sense of control awareness
(1) June 25 to the inpatient department, the emergency department issued the "diagnostic criteria for hospital-acquired infections", the doctor manually a book, and issued a review question, the monitoring team to study seriously, July 6 department closed-book examination, the Hospital Infection Department supervised,**** 26 doctors took the exam. All 90 points or more.
(2) July 12 on the medical, nursing, technical personnel and new and internship personnel "hand hygiene standards, hospital sensory knowledge should know and should be trained *** 81 people, after the examination, all qualified.
(3) November 2, organized by the Medical Department, Hospital Sensory Division of the hospital's medical, nursing, technical staff for the new version of the "Disinfection Technology Specification for Healthcare Institutions" training, 85 participants, and finally passed the exam.
(4) Our hospital leaders pay great attention to hospital infection control, sent the director of the hospital sensory department, the director of the Department of Nursing, operating room nurses to participate in the Yangquan City Health Bureau of knowledge of the infection teacher training, sent the supply room Tian Yuying to the First People's Hospital of Yangquan City, "Disinfection and Supply Center" training and internship.
Third, the monitoring of the reverse:
(1) to assist the inspection department of the key departments of the air disinfection effect of monitoring every month, and other departments once a quarter.
(2) supply room physical and chemical monitoring per pot, with records, unqualified resolutely not issued.
(3) UV lamp monitoring every six months, unqualified timely replacement.
(4) of the hospital infection cases of each department monthly implementation of the zero reporting system, the hospital infection department monthly in-depth department to investigate the leakage situation, this year *** admitted 1,766 people infected 6 people, the infection rate of 0.34% leakage rate of 16%, the targeted monitoring of 61 cases of clean surgical incision, 0 cases of infection, clean surgical A healing rate of 100%, catheter-related urinary tract infection monitoring 294 people, infection 2 people infection rate of 0.68% routine instrument disinfection qualification rate of 100%, one person, one needle, one tube sterilization implementation rate of 100%.
(5) November 15, the city CDC hospital infection key departments of environmental hygiene and sterilization effect of annual monitoring.
(6) November 27 on the inpatient present illness rate survey, inpatient **** 29 people, 28 people investigated, the actual rate of 96.6%. The survey results of the present rate of 3.45%, omission rate of 0%, antimicrobial drug utilization rate of 72.4%, higher than the Ministry of Health 60% of the standard.
(7) Monthly collection of data related to hospital-wide infection surveillance, statistics. Do monthly summary, quarterly feedback (quarterly newsletter), annual summary.
(8) with the cooperation of the Department of Prevention and Protection, the hospitalized patients telephone call back people to seek the views of patients, satisfaction rate of % to bring greetings to patients at the same time, but also timely detection of surgical incision infection cases.
Four, strengthen the medical waste management
with the logistics section to strengthen the routine supervision and inspection of medical waste is the hospital's medical waste in the existing conditions of collection, classification, handover, registration, incineration to achieve the standardized management, did not occur in the loss of medical waste, leakage. In particular, with the Laboratory Department of each bag of expired blood tracking treatment, no bag to the outside loss caused by adverse events.
Fifth, the implementation of the system, check in place
Seriously do a good job in the daily work, with the hospital's comprehensive target inspection, refinement of the standard, the results of the inspection of the director of the regular meeting of the Department of notification, rectification of deficiencies.
Six, the management of medical personnel occupational protection
Strengthen the medical staff of their own safety, to prevent sharp injuries and other occupational exposure management. From hand hygiene, the use of protective gear to start, improve the awareness of the medical staff of occupational protection, the annual occupational exposure of one case, not infected with blood-borne infectious diseases.
Existing problems:
1, according to the "hospital disinfection supply center management norms", our hospital supply room is in urgent need of change. The higher department inspection has been proposed many times, and the nursing department has sent people to study.
2, the bacterial room construction of the laboratory.
3, sewage treatment.
In short, some aspects of our hospital infection potential is still very serious, we firmly believe that as long as the leadership attaches importance to the cooperation of our functional departments, each with their own responsibilities, regular management, hospital infection control work can be done.
hospital infection work summary 5感控科按照《hospital infection management quality assessment form》定期在院内（包括各社区卫生服务站）开展自查。 Now make a summary of the hospital infection work in this quarter, as follows.
First, the development of corrective measures
1, clear hospital infection management by the Medical Department is responsible for. The hospital recruited a licensed physician as a hospital infection specialist, recently participated in the Guangdong Provincial Hospital Association organized by the Guangdong Provincial Hospital Infection Basic Theory and
Practical Skills Job Training Course and the 20xx Hospital Infection Management Lingnan Spring Forum ", by the examination qualified to receive the certificate of training for the post of hospital infection management.
2, re-adjustment of the hospital infection management organization, to further clarify the Hospital Infection Management Committee, hospital infection specialists and the departments of hospital infection management team's responsibilities; clear functional departments, including the Medical Department, Nursing Department, General Affairs, Pharmacy, Laboratory and Prevention and Protection of the Department of the responsibility.
3, the development of hospital infection management quality assessment form, weekly inspection of hospital infection management in various departments.
Second, the hospital infection work summary
1, self-examination
(1) organizational construction. Comprehensive section implementation is relatively good, has made this room to control hospital infection work plan and division of responsibilities.
(2) strict implementation of the principle of aseptic operation and operating procedures. The concept of asepsis is stronger in the operating room. Outpatient emergency, general medicine, obstetrics and gynecology generally have cotton swabs opened without labeling the date of opening, alcohol, iodine vapors, saline without labeling the date of opening, expired without replacement, etc., but after self-inspection and feedback, they have been corrected. Medical staff and cleaning company cleaning staff did not wear isolation gowns, masks, hats into the delivery room, by the director of obstetrics and gynecology department and the head nurse's supervision and education, have been better resolved.
(3) the strict implementation of sterilization and isolation system. Each department treatment car is equipped with quick-drying hand disinfectant, the implementation of one person, one needle, one tube, one hand-washing system. Each treatment room, dressing room and other daily ultraviolet disinfection 2 times, every 2 weeks with 95% alcohol wipe, records are perfect.
(4) sterilization effect monitoring. All departments are in line with the requirements, the use of chlorine disinfectant daily concentration monitoring and records, the use of glutaraldehyde sterilizer weekly concentration monitoring and records.
(5) medical waste management. Prevention and Protection Department, Obstetrics and Gynecology, outpatient emergency medical waste mixed in the living garbage cans, after self-inspection feedback, has been corrected.
2, inpatient case monitoring
45 inpatient cases have been monitored, of which 16 comprehensive internal medicine, comprehensive surgery 9, Obstetrics and Gynecology 20, did not find hospital infection omission.
3, hospital-acquired disease case investigation
This quarter there were four cases of hospital-acquired disease, including 1 case of obstetrics and gynecology, 3 cases of comprehensive internal medicine, all respiratory tract infections. The medical department hospital infection staff immediately carry out case investigation to verify the situation.
4, medical personnel occupational exposure
This quarter there were three medical personnel exposure, including two nurses in the Department of Integrated Medicine, a nurse in the Department of Prevention and Protection. The Medical Department has made appropriate treatment of occupational exposure personnel, do a good job of case investigation and registration, and tracking and monitoring.
5, hospital sensory training
to do a quarterly training.
6, medical waste collection, transportation and temporary storage
All departments are doing a good job in the classification of medical waste collection. Medical waste storage room medical waste is stored neatly, no dirt, blood and water outflow; there are obvious medical waste warning signs and "no smoking, eating and drinking" warning signs. There are handover records for medical waste. After the transportation of medical waste, the temporary storage room can be cleaned and disinfected in a timely manner.
7, the hospital disinfection supply center
Supply room workroom is clean and tidy, there are ultraviolet disinfection records and wiping records, record specification. Each pot of autoclave sterilization has a record and test paper monitoring.
Third, there are problems and recommendations
1, outpatient emergency, obstetrics and gynecology, pediatrics have not made the division of labor of the personnel of the hospital sensory team of the department and hospital sensory team work plan.
Suggestions: If you do not have the responsibility of the hospital sensory team, a clear division of labor, and a work plan, please implement it as soon as possible.
2, the departments sometimes appear cotton swabs, alcohol, povidone-iodine, saline is not labeled with the opening date, the expiration date is not replaced.
Recommendation: Each department should always pay attention to the cotton swabs, alcohol, iodine, saline whether labeled with the opening date, whether the expiration date has been replaced.
3, medical waste packaging, containers on the Department of Chinese labels, Chinese labeling content should include: medical waste generation unit, date of generation, category and the need for special instructions.
Suggestions: medical waste packaging, containers should be tied Chinese labeling, Chinese labeling content should include: medical waste generation unit, date of generation, category and the need for special instructions, etc.
4, medical waste packaging, containers should be labeled in Chinese.
4, containing more than 3/4 of the packaging or containers of medical waste; packaging or containers of the seal is not tight, tight.
Recommendations: Do not fill more than 3/4 of the package or container; the seal of the package or container should be tight and tight.
5, the departments failed to strictly implement the "Guidelines for the clinical application of antibacterial drugs", failed to achieve the rational application, according to the indications for the use of drugs. The medical department is not in place to supervise the rational application of antimicrobial drugs.
Suggestions: Each department should strictly implement the Guiding Principles for the Clinical Application of Antimicrobial Drugs to achieve rational application and use of drugs according to indications. The medical department should increase the supervision of the rational application of antibacterial drugs.
6, the monthly environmental monitoring is not well implemented.
Suggestion: The monthly environmental monitoring should be effectively implemented.
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