1. Hospital decontamination work self-examination report
According to the Municipal Health Bureau issued the "notice on the city's health care units disinfection and isolation special supervision and inspection of" the relevant content of the hospital organization hospital infection management committee personnel on the above work carried out a serious self-check, and is now self-examination of the work of the report is as follows.
First, the main practices and results
1, strengthen organizational leadership, and further implement the "Hospital Infection Management", "Hospital Isolation Technical Specification", "Disinfection Technical Specification for Healthcare Institutions" and related hospital infection management standards, norms. Our hospital has set up a hospital infection management committee headed by the vice president in charge, perfected the hospital infection management system, and formulated the post duties of hospital infection monitoring personnel at all levels with clear responsibilities. The Department of Hospital Infectious Disease is responsible for the hospital's disinfection and isolation supervision, and timely guidance to the relevant work of the departments, and seriously grasp the daily disinfection work. Regularly or irregularly, it organizes supervision and inspection of disinfection work of each department, and collects, counts and analyzes relevant data of the whole hospital. Emphasize the responsibilities of each department disinfection isolation team, strengthen the training of disinfection isolation team members, and regularly check the implementation of the relevant systems and norms, so that each department's understanding of the importance of disinfection and isolation work gradually increased.
2, strengthen the supply room disinfection management. The hospital leadership attaches great importance to the construction of the supply room to ensure the implementation of hospital disinfection. The supply room adhere to the "three areas", "three points", "three channels". In the pulsating vacuum pressure steam sterilization, adhere to the use of instructions outside the package tape, the use of instructions inside the package card, daily process monitoring, weekly biological monitoring, to ensure the quality of sterilization.
3, 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.
4, strengthen the hospital disinfection and isolation knowledge training, improve the medical staff disinfection and isolation knowledge, so that the clinical medical staff spontaneously participate in the disinfection and isolation management. Clinicians and nurses are trained at different levels and with different contents, so that everyone understands the key contents they must master.
5, the hospital laundry staff can implement the laundry hygiene and disinfection system, to maintain a clean environment in the laundry, the staff to work neatly dressed to do their own protection. Every day for the fixed collection of dirty quilt material to do sub-check, soaking, washing, mending, folding, storage in accordance with the process. Blood, body fluids contaminated clothing separate disinfection cleaning, disinfection using disinfectant chlorine content ≥ 500mg / L, time not less than 30 minutes.
6, endoscopy room seriously against the "endoscopy cleaning and disinfection technology operation specification" requirements, do a good job of endoscopy cleaning and disinfection of the registration work, the registration content, including the patient's name, the use of endoscopy number, the time of cleaning, disinfection time and the operator's name. Improve the use of protective facilities such as impermeable aprons when cleaning endoscopes, as well as the use of timer control in the cleaning, disinfection or sterilization time of endoscopes and accessories. Use multi-enzyme cleaning and disinfecting agents in the endoscopy room. At the same time to strengthen inter-departmental communication and contact, synergistic good endoscopy diagnosis and treatment of pre-screening, the initial screening of disease, strict diagnosis and treatment of indications.
7, the Department of Stomatology to strengthen the sterilization management of diagnostic and therapeutic instruments, such as oral pliers and other sterilization requirements of the high number of instruments and the use of high-temperature and high-pressure sterilization, to achieve a safe, accurate and effective disinfection requirements. In addition, the department's sterile goods arrangement has been organized, and made the corresponding provisions, so that its storage in good order and in line with the norms.
8, to strengthen the management of occupational exposure of medical staff, to protect the safety of employees, to strengthen the knowledge of occupational exposure of medical staff training, standardize the disposal process of sharp instruments. The personnel who have been exposed to occupational exposure according to the type of exposure source for tracking and monitoring and guidance to ensure the safety of medical staff.
9, conscientiously implement the "Regulations on the Management of Medical Waste", clarify the responsibilities of various types of personnel, 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 medical waste and living garbage mixed. Medical waste is collected and transported to the temporary storage point to avoid leakage, loss and other undesirable situations.
Second, there are problems
Hospital infection management system is not comprehensive, the details of hospital infection management work is not enough, part of the medical staff of the hospital disinfection and isolation awareness needs to be strengthened, there is a lack of knowledge, disinfection and isolation measures, some details still need to be strengthened, and the system implementation needs to be further improved; the layout and flow of the key departments (maternity wards, endoscopy rooms) need to be further standardized. Standardization. Some departments are not fully equipped with disinfection hardware, and the management of the hospital sewage system needs to be strengthened.
Third, the improvement measures and efforts
1, to further improve the hospital infection management system and implement the medical staff to strengthen the relevant knowledge learning.
2, improve the hospital departments disinfection isolation, nosocomial infection report, medical waste disposal system to regulate the behavior of hospital personnel.
(1) 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, reduce the incidence of hospital infections and protect the health of patients and health care workers. Give full play to the binding effect of the system, so that the implementation of the work in practice.
(2) treatment and disposal of patients adhere to the one person one needle one tube one with a disinfection, beds using wet cleaning, a set of beds, bedside cabinets, a table, a rag and a disinfection, the patient was discharged from the bed unit according to the end of the disinfection process.
(3) treatment room sterile items and disposable items are placed separately, sterile items are opened to record the opening time, daily ultraviolet disinfection of the air, the time is cumulative, monitoring records.
3, has planned a good maternity ward to re-standardize the construction and adjustment of endoscopy room supporting, will be configured according to the relevant set of requirements for endoscopy waiting room, treatment room, cleaning and disinfection room.
4, disposable goods management.
(1) The hospital infection management team on the procurement of disposable medical supplies, management and post-use treatment to fulfill the supervision and inspection duties.
(2) Where the purchase of disposable medical supplies for use in our hospital, "three certificates" are complete, with disinfection and sterilization mark, date of production, expiration date, product packaging meets the requirements.
(3) the establishment of the pharmacy register, items stored in a cool, dry, well-ventilated shelves.
5, medical waste management.
(1) developed a medical waste disposal process, disinfection register, the development and disposal unit personnel handover, double-signature system.
(2) Clinical Section set up a medical waste statistics book, hospital specialized personnel and medical waste collection personnel handover double-signature.
(3) improve the hospital sewage disposal system, process, in line with the hospital infection management requirements.
2. Self-inspection report on hospital decontamination
Hospital disinfection is one of the most important means of preventing and controlling hospital-acquired infections, preventing the spread of infectious diseases, maintaining the quality of medical care, and safeguarding the safety of patients and health care workers. Planned, continuous and systematic hospital disinfection and infection monitoring is an important part of effective prevention and control of hospital infections and infectious disease outbreaks and epidemics in hospitals. Medical Department on April 24, 20xx organized a hospital disinfection and sterilization knowledge training.
First, the main content:
Hospital infection management methods, disinfection technical specifications, hospital disinfection health standards and medical waste management regulations.
Second, the effect of training:
The training should be 20 people, the actual 20 people. During the training period, the participants recorded seriously, actively ask questions, the site discussed warmly. Through this training can not only increase the accumulation of knowledge of sterilization, but also to change the clinical medical staff on the implementation of sterilization system of resistance, strengthen the medical staff self-occupational precautions, but also familiar with the relevant laws and regulations, standardized procedures, standardized behavior, and enhance the awareness of sterilization.
Third, training, work shortcomings:
3. Hospital decontamination work self-examination report
xxxx year, in the hospital under the correct guidance of the Department of Nursing, I conscientiously fulfill the duties of the medical work, along with everyone else to work hard to complete the tasks assigned by the head of the nurses. At this time of the old and welcome the new, looking back, looking forward, summarized as follows:
Over the past year, I actively participate in the business training organized by the hospital, and conscientiously study the political ideological theory and nursing expertise, consciously abide by the code of medical ethics of medical personnel, in front of the work, the overall situation, do not fight for fame and fortune, regardless of gain or loss, and do their best to do a good job. In the course of daily work, I always find ways and means to do my best to solve, on time, according to quality, according to quantity to complete each task, no error. Strictly abide by the provisions of the hospital, can independently perform their duties, and strive to improve work efficiency and quality of work, "service clinic, care window", in the active service to do articles, to ensure the normal development of the work of the supply room. Over the past year, I have not been late, early departure phenomenon, always stick to the workstation. In order to ensure the quality and safety of sterilized items, strictly in accordance with the technical specifications for disinfection, it is important to do a good job of monitoring and management of sterile items in the supply room.
According to the overall planning of the hospital and the specific requirements of the head nurse, I always grasp the work of seven "strict" quality monitoring gate: First, strictly according to the operation and procedures to do things off; Second, pay strict attention to keep the work room clean and sanitary off; Third, strictly good recovery of various types of goods processing quality off; Fourth, strictly good storage of sterile goods off; Fifth, strictly good The storage of sterile items; five is strictly good quality monitoring of sterile items; six is strictly good quality of outsourced disposable medical supplies; seven is strictly good on the use of disposable items after the recycling process, effectively preventing the pollution of the surrounding environment and to eliminate the re-circulation of the link.
Looking back on the work of the year, I have made new progress in thinking, learning and work, but also recognize their own shortcomings. These shortcomings, the need to work in the future hard study, hard work to improve, improve the service process, improve service awareness, build a harmonious doctor-patient relationship, in order to promote the hospital's sustained, rapid, healthy and harmonious development, to protect the people's health and safety of life and make unremitting efforts.