Hospital infection management self-inspection report
In order to further strengthen the management of hospital infection, ensure the quality of medical care and patient safety, the hospital infection inspection instructions were carried out according to the requirements of the superior health administrative department, and the Measures for the Management of Hospital Infection were conscientiously implemented, from the aspects of hospital infection organization management, hospital infection monitoring, key departments (such as operating room, stomatology, treatment room, laboratory, etc.), and high-risk factors of key departments. Self-examination was carried out seriously in the aspects of hospital-acquired cases report and disposal, occupational exposure of medical staff, hand hygiene, disinfection and isolation process, and management of disposable medical supplies after use. The results of self-examination are reported as follows: < P > 1. Members of the organization? Team leader: Zhou Jianzhong
Deputy Team Leader: He Qu, Lu Xuemei
Members: Directors of all disciplines, head nurses, team leaders? Second, further improve the management system and implement it:
Formulated various rules and regulations of hospital infection management (such as hospital infection control system, sterilizer management system, disinfection and isolation system, hospital infection case registration and reporting system, infection control system, measures and workflow of key departments in the hospital, occupational exposure disposal process of medical staff, medical waste management system and disposal process, hospital infection management inspection standards, etc.), and required relevant personnel to study hard and implement them. The implementation of the supervision and inspection system of departments under regular and irregular conditions. Due to the attention of leaders, clear responsibilities at all levels and good operation, there has been no outbreak of nosocomial infection since the hospital was established.
Third, strengthen the hospital management of key departments:
1. Hospital leaders attach great importance to the management and supervision of key departments, so as to achieve "three areas", "three separation" and "three channels" and ensure that articles are cleaned from pollution (according to the process of recycling-classification-cleaning-inspection and packaging-sterilization-storage-distribution);
the principle of air from clean to dirty. Three zones: polluted zone, clean zone and sterile zone. Three separation: the polluted recycled materials are separated from the clean materials, the initial washing is separated from the fine washing, and the unsterilized and sterilized materials are separated. Three channels: dirt channel, sterile goods channel, and staff channels do not cross. ?
2. The hospital has no pressure steam sterilization equipment, and signed an outsourcing disinfection contract with Chengdu Jinxin Psychiatric Hospital, with two-way signature registration. Adhere to the use of indicator tape outside the aseptic package and indicator card inside the aseptic package for self-monitoring and daily monitoring, ensuring the quality of disinfection and sterilization.
3. Hospital infection monitoring has been effectively implemented, and there is a perfect monitoring system. All departments regularly monitor the number of bacteria in air, surface of objects, disinfectants in use, staff hands and sterile articles as required, and the hospital infection department randomly checks key departments of key departments to ensure the environmental quality of the hospital.
Fourth, do a good job in disinfection, isolation and infection monitoring in clinical departments:
1. Strictly implement disinfection and isolation, strictly abide by aseptic operation technology, set up infection management and workflow in operating room, supply room and hospital, and clean disinfection process.
2. One person, one needle, one tube, one use and one disinfection should be adhered to in the treatment and disposal of patients. The sickbed should be cleaned in a wet way, and one bed should be set. The bedside table should be disinfected with a rag. After the patient is discharged from the hospital, the bed unit should be treated as terminal disinfection.
3. Sterile articles in the treatment room are placed separately from disposable goods. After the sterile articles are opened, the opening time is recorded, and the air is disinfected by ultraviolet rays every day. The time is accumulated, and the monitoring is recorded. The air bacteria culture is done once every quarter.
Fifth, strengthen the training of hospital infection knowledge, and improve the awareness of hospital infection prevention and control of medical staff:
We have formulated a hospital infection training plan, paid special attention to publicity, education and training, and conducted training and assessment on the knowledge of hospital infection, hand hygiene and epidemic prevention and control of infectious diseases for new medical staff and medical staff in our hospital every year.
VI. disposable goods Management:
1. The Hospital Infection Management Association will perform supervision and inspection duties on the procurement, management and post-use disposal of disposable medical supplies.
2. All disposable medical and health products purchased for hospital use have complete "three certificates", disinfection and sterilization marks, production date and expiration date, and the product packaging meets the requirements.
3. There are "three certificates" of disposable goods and sterilized medical instruments in the drug inventory, and a registration account book is established. The goods are stored in a cool, dry and well-ventilated shelf.
4. Disposable medical supplies are destroyed, recycled and treated harmlessly after use, and the records are available.
VIII. Medical waste management:
The Hospital Infection Management Section has formulated the medical waste treatment process, set up a registration book for medical waste after use, and handed it over to the personnel of the disposal unit with double signatures.
Hospital Infection Management Self-inspection Report
According to the spirit of the instructions of higher authorities on carrying out special inspection of hospital infection, we thoroughly implement the Measures for Hospital Infection Management, carefully find out the problems existing in hospital infection management, reporting and disposal of medical institutions, further strengthen hospital infection management, effectively prevent and control hospital infection and iatrogenic infection of infectious disease pathogens, drug-resistant bacteria, conditional pathogenic bacteria and other pathogenic microorganisms, enhance hospital prevention and control capabilities, and ensure people's health and life safety. The leaders of the hospital attached great importance to it, and the dean personally organized and implemented it. The hospital infection management, self-examination and self-correction were carried out with emphasis, location and measures.
1. Strengthen the organization and leadership to ensure the smooth development of the self-inspection of nosocomial infection management. ?
clear responsibilities and division of responsibilities: each clinical department is responsible for the monitoring work of the department and reports the relevant situation to the hospital infection group on time. Due to the implementation of the work at different levels, the smooth development of nosocomial infection management in our hospital was ensured.
2. Seriously carry out self-examination and self-correction, and the hospital infection monitoring has been effectively implemented. The monitoring system in our hospital is as follows:
1. There is no hospital-feeling monitoring report because the hospital monitors air, objects and watches unconditionally.
2. Monitor disinfectants (alcohol, iodophor, dialdehyde, etc.) in use once a month. ?
3. Monitor the intensity of ultraviolet lamp once a month.
4. The pressure steam furnace (each sterilization package has a chemical indicator card) is monitored monthly. ?
5. disposable goods (syringes, infusion sets, etc.) is initially soaked after use, and then recycled for a series of harmless treatments such as serious damage and incineration.
6. The operating room and delivery room shall be strictly divided into clean area, semi-clean area and polluted area, with corresponding supporting facilities. The facilities, workflow, medical instruments, appliances and personnel dress meet the requirements of the Code. ? Management of medical waste:
1. Classified collection, transportation to temporary storage and destination of medical waste are standardized and registered. Code for management of storage, use and debris destination of disposable medical supplies. ?
2. Have relevant staff occupational health, safety protection measures and knowledge training. ? Hand hygiene management:
1. There is a hospital hand hygiene system and specific implementation measures.
2. The hand hygiene knowledge of 5 medical staff was checked, and they were all familiar with hand hygiene knowledge. ?
3. Hand washing facilities meet the requirements. ? We still have many problems through self-examination:
1. The knowledge and control consciousness of nosocomial infection are shallow, and the aseptic operation of individual medical staff is not strict enough.
2. Some departments are not equipped with disinfection hardware, and the concept of disinfection and sterilization needs to be strengthened. ?
3. The architectural design of operating room and delivery room is not reasonable enough. ?
4. The details of nosocomial infection control are not enough.
5. The registration of nosocomial infection is incomplete, and some departments do not pay attention to filling in the registration form of nosocomial infection.
6. Lack of seriousness in filling in infectious disease cards.
in view of the problems existing in our hospital, we should carefully analyze, find ways and measures to solve the practical problems:
1. Establish an organization, clarify responsibilities, assign responsibilities to people, and improve the system to restrain people.
2. check the medical records in the medical record room regularly, check that the filling of hospital infection cases meets the requirements of superiors, and do a good job of missing and filling in hospital infection cases. ?
3. Formulate and implement various rules and regulations on hospital infection management, such as disinfection and isolation system, hospital infection case registration system, aseptic operation system and infectious disease reporting system. ?
4. Pay special attention to publicity, education and training, train and assess the newly graduated medical staff, and assess the hospital infection management and infectious disease knowledge of the medical staff in the hospital. ?
5. carry out indoor and outdoor sanitary cleaning and rectify dead corners. ?
6. Do a good job in the registration of activities related to nosocomial infection.
third, further improve the management system and implement it? Hospital infection management system is the basis and important guarantee to do a good job in hospital infection. It is very important to formulate and improve a set of scientific and practical management systems to regulate the behavior of hospital personnel and implement them conscientiously, so as to improve the awareness of prevention and reduce the incidence of hospital infection. Give full play to the binding role of the system, so that all work can be implemented. ?
fourth, continue to do a good job in disinfection and isolation and infection monitoring in clinical departments. ?
The hospital strengthens the disinfection and isolation and infection monitoring of clinical departments. Check regularly and irregularly, and deal with the problems found in time. When infectious patients are found, they should register and report the epidemic situation in time. Toxic, harmful and infectious sewage and dirt must be disinfected. In addition to strictly disinfecting the reusable items, our hospital has increased the utilization rate of disposable sterile medical supplies, greatly reducing the possibility of nosocomial infection.
invalid disposable articles are used by patients. Due to strict control, no patient used unqualified disposable sterile medical supplies. For used disposable articles, all departments have always insisted on destroying, disinfecting and recording. Therefore, the destruction rate of disposable empty needles, infusion sets and urine bags in our hospital is 1%.
sixth, strengthen the training of hospital infection knowledge, and improve the awareness of hospital staff to control hospital infection. ?
in combination with the actual situation of our hospital, we will organize medical accident treatment regulations, disinfection and safety knowledge training, and train the medical staff in the hospital on the prevention and control of hospital infection, so as to enhance their awareness of preventing and controlling hospital infection. Improve the level of prevention and control of nosocomial infection in our hospital. We believe that as long as we constantly sum up experience and learn with an open mind, we will do a better job in hospital infection control.
self-inspection report on nosocomial infection
In accordance with the spirit of instructions from higher authorities, we thoroughly implement the Measures for the Management of Hospital Infection, carefully find out the problems existing in the management, reporting and disposal of nosocomial infection in medical institutions, further strengthen the management of hospital infection, effectively prevent and control infectious disease pathogens and iatrogenic infections, enhance the prevention and control ability of hospitals, and ensure the health and life safety of people. The hospital leaders attached great importance to it, personally organized it, and implemented it. From establishing organizations, perfecting systems and responsibilities to front-line inspectors, they carried out hospital infection management, self-examination and self-correction in a comprehensive, standardized and scientific way.
first,? Strengthen organization and leadership to ensure the smooth development of nosocomial infection management.
Our hospital has set up a hospital infection management team:
The hospital infection team headed by the secretary is responsible for the control of the whole hospital and gives guidance to the lower departments. Earnestly pay special attention to daily work, supervise and inspect the nosocomial infection control work of all subjects regularly and irregularly, collect and count the relevant data of the whole hospital, and report to the hospital leading group. Each clinical department has a special person who is responsible for the monitoring of the undergraduate course, and reports the relevant situation to the hospital infection group on time. .
Second, seriously carry out self-examination and self-correction
After several self-examinations, we still have many problems:
(1) The knowledge and control awareness of nosocomial infection among employees are shallow. ?
(2) Some departments are not equipped with disinfection hardware. ?
(3) The hospital infection control system is not comprehensive. ?
(4) The details of nosocomial infection control are not enough.
(5) hand hygiene is not in place.
[6] The equipment of the endoscopy room is not up to standard, and the disinfection is unqualified
[7] The hospital infection cases are not reported in time (the doctor's diagnosis of hospital infection is not clear enough.
⑻ The management of acupotomy room is not in place, and the staff in the department have a weak sense of infection control. ?
⑼ The management of abortion room is not in place, and the staff in the department have a weak sense of infection control. ? In view of the problems existing in our hospital, the nosocomial infection management team analyzes them one by one, and tries to find ways and measures to solve the existing practical problems: < P > (1) Establish an organization to clarify responsibilities, and the responsibility lies with people. ?
(2) improve the system to bind people.
(3) Improve hand hygiene facilities, conscientiously implement hand hygiene standards, raise awareness, and conduct regular hand hygiene monitoring.
(4) make a training plan for nosocomial infection to improve the ideological awareness of employees. ?
(5) Carry out indoor and outdoor sanitary cleaning.
[6] Do a good job in the registration of nosocomial infection-related activities, and improve the purchase of basic items in various subjects to ensure the normal operation of nosocomial infection control.
once, through medical training, doctors can master the diagnostic criteria of nosocomial infection, report it in time, improve records and effectively control nosocomial infection.
⑻ Endoscopic room should be built according to standardization, and soft endoscope should be washed as required, and enteroscopy, stomach meridian and laryngoscope should be included in the key monitoring range. Ensure patient and medical safety.
⑼ Strengthen the concept of aseptic operation of doctors in the acupotomy room and abortion room, train them, improve the facilities and equipment in the acupotomy room, and conduct regular spot checks, inspection and supervision. ? Third, further improving the management system and implementing the
hospital infection management system is the basis and important guarantee for doing a good job in hospital infection. A set of scientific and practical management systems has been formulated, and the systems of nosocomial infection management, disinfection and isolation of various departments, nosocomial infection report, discussion of critical and urgent death cases, referral of special cases, sewage treatment and so on have been improved. To regulate the behavior of hospital personnel. Strengthening the construction and study of the system, and conscientiously implementing it, is extremely important for improving the awareness of prevention and reducing the incidence of hospital infection. Give full play to the binding role of the system, so that all work can be implemented. ?
fourth, the disinfection management in the disinfection room has been strengthened.
the logistics department often checks indoor walls and ceilings to keep them smooth, free from cracks and falling dust. The arrangement of disinfection room is reasonable, and the "three areas" should be adhered to. "Three separate". ? Three zones: polluted zone, clean zone and sterile zone. ? 3. Separation: separation of waste recycling and net distribution;
primary washing is separated from fine washing;
unsterilized items are separated from sterilized items;
during pressure steam sterilization, we insist on using indicator tape outside the package and indicator card inside the package for self-monitoring, which ensures the quality of disinfection and sterilization and carries out biological monitoring.
5. Continue to do a good job in disinfection, isolation and infection monitoring in clinical departments. ?
1. According to the Law on the Prevention and Control of Infectious Diseases, the Measures for the Administration of Disinfection and the Provisions on Hospital Infection, the hospital has strengthened the disinfection, isolation and infection monitoring of clinical departments. Check once every half month, and deal with the problems found in time. When infectious patients are found, they should register and report the epidemic situation in time. Toxic, harmful and infectious sewage and dirt must be disinfected. In addition to strictly disinfecting the reusable items, it increases the utilization rate of disposable sterile medical supplies and greatly reduces the possibility of nosocomial infection. In the disinfection solution replacement and instrument soaking inspection