1, full-time staff does not meet the requirements. Hospital infection prevention and control knowledge training and hospital infection Committee meetings are not held regularly.
2. The awareness rate of hospital infection system is not high, and the implementation is not in place.
3, there is no microbial room, bacterial room. No environmental health monitoring was carried out.
4. A comprehensive monitoring of nosocomial infection was carried out, and the monitoring data was inconsistent with the actual situation.
5. The awareness rate and implementation rate of hand hygiene among medical staff are low.
6, individual departments, equipment cleaning is not clean. The layout of the supply room is unreasonable, the hospital has not carried out centralized cleaning and disinfection of medical devices, and the supply room has not carried out biological monitoring.
7. The hospital did not carry out monitoring of multi-drug resistant bacteria.
8. Some departments did not use glutaraldehyde disinfectant concentration test card, and there was no record. The monitoring of ultraviolet intensity in individual departments was not carried out on time.
9. There is no daily operation monitoring record for sewage treatment. Medical waste warning signs are incomplete.
Second, the rectification measures:
1, strengthen the study and training of full-time staff, participate in the on-the-job training of hospital infection management personnel in medical institutions organized by the health department, and hold relevant certificates. Make a training plan for all employees and conduct regular training to implement the system. According to the system of hospital infection committee meeting, the hospital infection committee meeting was held.
2. Organize departments to learn the hospital infection system, so as to implement the system.
3. Actively cooperate with the Municipal People's Hospital (Second Hospital) and sign an agreement to monitor the environmental sanitation of the hospital on a regular basis. Send personnel to study microbiology (already studying in regional hospitals). Set up a microbiology room in the new hospital.
4. To carry out comprehensive hospital infection monitoring, it is necessary to go deep into clinical departments, carefully collect all kinds of data of patients, analyze the distribution of hospital infection in a certain population and its influencing factors, determine the causes, results, prevention and implementation of monitoring, ensure the accuracy of monitoring data, and analyze the results every month and feed them back to various departments.