Overview of hospital infection management

First, formulate rectification measures.

1, it is clear that the medical department is responsible for hospital infection management. The hospital recruited 1 medical practitioners as specialized personnel in the hospital sense, and recently participated in the "Guangdong Provincial Hospital Infection Basic Theory and Practical Skills Post Training Course and 20 10 Lingnan Hospital Infection Management Spring Forum" organized by Guangdong Provincial Hospital Association, and obtained the post training certificate of hospital infection management after passing the examination.

2. Reorganize the hospital infection management organization, and further clarify the responsibilities of the hospital infection management committee, hospital infection specialists and hospital infection management teams in various departments; Clarify the responsibilities of various functional departments, including medical department, nursing department, general affairs department, pharmacy department, laboratory department and preventive medicine department.

3, develop hospital infection management quality evaluation table, check the hospital infection management subjects every week.

Second, the hospital feeling work summary

1, self-checking situation

(1) organizational construction. The general department carried out well, and formulated the work plan and division of responsibilities for controlling hospital infection.

(2) Strictly implement aseptic operation principles and operating procedures. The concept of sterility in operating room is very strong. In outpatient and emergency departments, general departments and obstetrics and gynecology departments, there are many problems, such as cotton swabs not marked with the opening date after opening, alcohol, iodophor and normal saline not marked with the opening date, and they have not been replaced after expiration, but they have all been corrected after self-examination and feedback. The problems of medical staff and cleaning staff of cleaning company entering the delivery room without wearing isolation gown, masks and hats have been well solved through the supervision and education of the director of obstetrics and gynecology and the head nurse.

(3) Strictly implement the disinfection and isolation system. The treatment vehicles in each department are equipped with quick-drying hand disinfectant, and the system of one person, one needle, one tube, one belt and one hand washing is implemented. Every treatment room, dressing change.

The room was disinfected with ultraviolet twice a day and wiped with 95% alcohol every two weeks, and the record was perfect.

(4) Monitoring of disinfection effect. All departments meet the requirements. Monitor and record the concentration of chlorine-containing disinfectant every day and glutaraldehyde disinfectant every week.

(5) Medical waste management. Medical waste is mixed in the dustbins of preventive medicine, obstetrics and gynecology, outpatient and emergency departments. After self-examination and feedback, it was corrected.

2, in-patient case monitoring

45 hospitalized cases have been monitored, including general internal medicine 16 cases, general surgery 9 cases and obstetrics and gynecology 20 cases. No loss of hospital feeling was found.

3. Case investigation of nosocomial infection cases

There were 4 cases of nosocomial infection in this quarter, including 3 cases of obstetrics and gynecology/KLOC-0, and 3 cases of general internal medicine, all of which were respiratory infections. Full-time medical staff immediately carried out case investigation to verify the situation.

4. Occupational exposure of medical staff

In this quarter, three medical staff were exposed, including two nurses in general department and nurses in preventive medicine department 1 person. The medical department has dealt with the occupational exposed personnel accordingly, made a good case investigation and registration, and conducted follow-up monitoring.

5, hospital sense training once a quarter.

6. Classified collection, transportation and temporary storage of medical wastes

All departments should do a good job in the classified collection of medical wastes. The medical wastes in the temporary storage room shall be stored neatly, without pollution and blood outflow; There are obvious warning signs of medical waste and warning signs of "No Smoking and Eating". Medical wastes have handover records. After the medical waste is shipped out, the temporary storage room can be cleaned and disinfected in time.

7, hospital disinfection supply center

The workshop of the supply room is clean and tidy, with ultraviolet disinfection records and wiping records, and the records are standardized. Each pot of high-temperature steam sterilization is recorded and monitored by test paper.

Three. Existing problems and suggestions

1, the departments of outpatient, emergency, obstetrics and gynecology, and child care have not formulated the division of labor and work plan of the hospital infection group.

Suggestion: Departments that haven't completed the responsibilities of the release team, defined the division of labor and made work plans should implement them as soon as possible.

2. Sometimes cotton swabs, alcohol, iodophor and normal saline are not marked with the opening date, and will not be replaced after expiration.

Suggestion: All departments should always pay attention to whether the cotton swabs, alcohol, iodophor and normal saline are marked with the opening date, and whether the expired ones have been replaced.

3. There are no Chinese labels on the packages and containers of medical wastes, and the contents of Chinese labels should include: the generating unit, date of generation, category and contents that need special explanation.

Suggestion: Medical waste packages and containers should be labeled in Chinese, and the contents of Chinese labels should include: the generating unit, date of generation, category and special description of medical waste.

4. The medical waste contained exceeds 3/4 of the package or container; The packaging or container is not tightly sealed.

Suggestion: Medical waste should not exceed 3/4 of the package or container; The packaging or container should be tightly sealed.

5. Each department failed to strictly implement the guiding principles of clinical application of antibacterial drugs, failed to use them rationally, and failed to use drugs according to indications. The supervision of the medical department on the rational use of antibacterial drugs is not in place.

Suggestion: All departments should strictly implement the Guiding Principles of Clinical Application of Antibacterials, so as to use drugs rationally and according to indications. The medical department should strengthen the supervision of the rational use of antibacterial drugs.

6. The implementation of monthly environmental monitoring is not in place.

Suggestion: monthly environmental monitoring should be effectively implemented.