Hospital infection inspection rectification report
Part IAccording to the county health bureau "on the neonatal room nosocomial infection and disinfection safety self-check notice" and on the safety of production emergency telephone notification of the relevant requirements combined with the creation of our hospital to create a first-class health hospitals related to the content of the hospital organization of the staff of the work of the above serious self-check and rectification. Self-inspection and rectification, is summarized in the following report:
I. Inspection content
(a) production safety: the hospital production safety management leading group of the whole hospital carried out a thorough inspection, including the various production safety regulations and systems development and implementation. Electricity and fire situation, flammable, explosive, narcotic drugs and other dangerous goods management as well as medical safety management and other projects, the details are as follows:
1, organizational leadership
The implementation of the leadership system of responsibility is good, set up by the president of the leading group of production safety, duty personnel in place, the rules and regulations sound.
2, the prevention of medical accidents
The implementation of the core system of medical safety, the rescue measures in place for patients with acute and critical illnesses. The hardware facilities of medical safety are perfect, and the facilities of the supply room, operating room and other departments are standardized. The rules and regulations of medical waste disposal are sound, and the disposal method is in line with the standard, so that there is a person who manages and takes responsibility for it.
3, emergency treatment of public health emergencies and health care security
For the possible occurrence of public health emergencies and disasters and accidents, the development of relevant emergency response plan, the establishment of a medical and health emergency response team, to maintain communication, the establishment of a medical rescue, health and epidemic prevention and other emergency supplies reserves.
4, security and fire protection
The establishment of emergency response plan, improve the security and fire protection duties, work system, personnel duty in place. The key key sections of the protection of the responsibility for the implementation of measures.
(B) hospital infection and sterilization safety
1, the establishment of the Hospital Infection Management Committee and the Hospital Infection Management Office, there are specific office staff, staff responsibilities are clear.
2, developed the "hospital infection management system", "hospital infection control program" "hospital infection control, isolation measures" "disinfection and isolation system. Rational use of antibiotics management approach," "sterilization effect monitoring system," "treatment room disinfection and isolation management system," "supply room, operating room, delivery room disinfection and isolation system," "delivery room cleaning measures," "medical waste disposal management system," and other hospital infection prevention and control system.
3, developed a hospital disinfection and isolation registration system, the disinfection effect of the test.
4, the entire hospital medical staff have participated in training on knowledge of hospital infection.
Second, the problems found
1, the fire apparatus is not in place.
2, the implementation of the infection system is not in place, disinfection effect monitoring is not timely enough, the registration is incomplete, no monitoring analysis.
3, part of the medical staff on the hospital infection is not enough attention, there is paralysis.
Third, corrective measures
1, immediately installed a good qualified fire apparatus.
2, held a staff meeting, the hospital infection system, hospital infection-related knowledge retraining, the development of the assessment system, the violation of the relevant hospital infection departments and personnel to be punished, and immediately on the hospital's disinfection testing and make an analysis of the disinfection measures are not standardized, corrective.
3, to create the standard as an opportunity to further improve the management system, especially the prevention and control of hospital infections related systems, to achieve a perfect infection management system, infection management organization is sound, infection control measures in place, infection management personnel have a clear responsibility to ensure that the realization of infection control objectives.
Part II
In accordance with the higher level on the development of hospital infection special inspection instructions, in-depth implementation of the "Hospital Infection Management Measures" to seriously find medical institutions in the management of hospital-acquired infections, reporting and disposal of problems, and to further strengthen the management of hospital infections, effective prevention and control of infectious disease pathogens, drug-resistant bacteria, conditionally pathogenic bacteria and other pathogenic microorganisms hospital infections and medical infections, and enhance the prevention and control of hospital infections and health-care infections. The hospital leadership attaches great importance to the hospital, the dean personally organizes the hospital infection prevention and control, and the hospital infection management and disposal of problems in reporting and disposal. Hospital leadership attaches great importance to the president of the personal organization, grasp the implementation of the focus, parts, measures to carry out the management of hospital infection, self-correction work.
First, strengthen the organization and leadership, to ensure the smooth implementation of the hospital infection management self-check work.
Clear responsibilities, division of labor: each clinical department is responsible for the monitoring of their own room, on time to the hospital infection team to report the situation. Due to the implementation of the work at all levels, to ensure the smooth development of our hospital infection management.
Second, seriously carry out self-examination and self-correction, hospital infection monitoring has been effectively implemented, the hospital's monitoring system are:
1. Because the hospital is not conditional on the air, the table, the watch to monitor the hospital infection monitoring report.
2. Monthly monitoring of disinfectants in use (alcohol, iodophor, Hundred Days' Aldehyde, etc.).
3. Monthly monitoring of the intensity of ultraviolet lamps.
4. Pressure steam ovens (with chemical indicator cards for each sterilization kit) are monitored monthly.
5. disposable items (syringes, infusion sets, etc.) after use, that is, in the initial immersion treatment, and then unified recovery for serious disfigurement and incineration and a series of harmless treatment.
6. Operating rooms, maternity wards, strictly distinguish between clean, semi-clean and contaminated areas, and have the appropriate supporting facilities. Facilities, workflow, medical equipment, appliances, personnel attire in line with the "norms" requirements.
Medical waste management:
1. Medical waste generated by the categorization of the collection, delivery of temporary storage, destination management standardization, registration. Disposable medical supplies storage, use and debris destination management standardization.
2. There are relevant staff occupational health, safety measures and knowledge training.
Hand hygiene management:
1. There is a hospital hand hygiene system, and specific implementation measures.
2. Sampling 5 medical staff hand hygiene knowledge mastery, are familiar with hand hygiene knowledge.
3. Hand washing facilities meet the requirements.
Through self-examination, we still have many problems:
1. Staff knowledge of nosocomial infections and control of awareness of the shallow, individual medical staff aseptic operation is not strict enough.
2. Some departments are not fully equipped with disinfection hardware, disinfection, sterilization concept to be strengthened.
3. Operating room, delivery room building design is not reasonable.
4. Nosocomial infection control details are not enough.
5. The registration of nosocomial infection is incomplete, and some departments do not pay attention to filling in the nosocomial infection registration form.
6. Lack of seriousness in filling out the infectious disease card.
For the problems in our hospital, serious analysis, think of ways to find measures to solve the practical problems:
1. Establishment of the organization, clear responsibilities, responsibilities to people, sound and perfect the system of constraints.
2. Regularly to the case room to view the medical records, check and urge the filling of hospital-acquired infections in line with the requirements of the higher level, and do a good job of hospital-acquired infections omitted to make up for the registration work.
3. Develop and implement various rules and regulations for hospital infection management, such as: disinfection and isolation system, hospital-acquired infection case logging system, aseptic operation system, infectious disease reporting system.
4. Grasp the publicity and education, training, new graduates of the medical staff for training and assessment, the whole hospital medical staff for hospital infection management and infectious disease knowledge assessment.
5. Carry out indoor and outdoor hygiene cleaning, rectify dead ends.
6. Do a good job of registration of activities related to nosocomial infection.
Third, further improve the management system and implement
Hospital infection management system is the foundation and important guarantee of hospital infection. Develop and improve a set of scientific and practical management system to regulate the behavior of hospital personnel, and conscientiously implement the implementation of the awareness of improving prevention, reduce the incidence of hospital infections is extremely important. Give full play to the binding effect of the system, so that the implementation of the work in practice.
Fourth, continue to grasp the clinical departments disinfection isolation, infection monitoring work.
The hospital to strengthen the clinical departments of disinfection isolation, infection monitoring work. Regular unscheduled inspections, the problems found in a timely manner. The discovery of infectious patients, to register and report outbreaks in a timely manner. Toxic, harmful and infectious sewage filth must be sterilized. In addition to checking the reuse of items strictly in accordance with the requirements of disinfection, our hospital increased the use of single-use sterile medical supplies, greatly reducing the possibility of nosocomial infection.
1. Every day to the department to understand whether there are cases of nosocomial infection, there is no omission, misreporting and so on. Each department will register and report the cases of nosocomial infections found to the hospital office in time and deal with them accordingly.
2. The hospital should seriously improve environmental hygiene, indoor hygiene, personal hygiene and dietary hygiene, and strengthen the hygiene of patients' publicity and education, in order to create a clean, quiet, comfortable and safe medical environment for patients.
V. Continue to manage the disposable supplies to ensure the medical safety of the patients and prevent social pollution.
In the purchase of disposable supplies, to strengthen the management, strict verification, check the quality. The purchase of disposable supplies for inspection, registration, the purchase of disposable supplies, disinfection of medicine and equipment to prevent unqualified products into our hospital. In the current year, none of the disposable products purchased by the hospital were unqualified. Strengthening the storage management of single-use sterile medical supplies, according to the requirements of the ground away from the wall storage. The hospital conducts quarterly inspections of single-use sterile medical supplies stored in the storehouse and various departments, and the nursing staff strictly checks the supplies before use to prevent expired and invalid single-use supplies from being given to 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 disposable supplies, each department has been insisting on disfigurement, disinfection and record, therefore, the hospital's disposable empty needles, infusion sets, urine bags, etc. disfigurement rate of 100%.
Sixth, strengthen the knowledge of hospital infection training, improve the hospital staff to control hospital infection awareness.
Combined with the actual hospital, the organization to carry out medical incident handling regulations, disinfection, safety knowledge training, etc., the whole hospital medical staff for the prevention and control of hospital infections related knowledge training, enhance the prevention and control of hospital infection awareness. Improve the level of prevention and control of hospital infection in our hospital. We believe that as long as we continue to summarize our experience and learn with an open mind, we will do a better job of hospital infection control.