2017年醫(yī)院感染管理工作督查記錄薄(醫(yī)技)

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44、染暴發(fā)應(yīng)急預(yù)案演練··························(0) 前言醫(yī)院感染是伴隨醫(yī)學(xué)科技進(jìn)步而發(fā)展的一種特殊感染形式，是當(dāng)前世界各國醫(yī)院面臨的重要公共衛(wèi)生問題之一，也是醫(yī)院現(xiàn)代管理的重要內(nèi)容和醫(yī)療質(zhì)量持續(xù)改進(jìn)的熱點(diǎn)、難點(diǎn)問題。近年來由于多重因素影響，國內(nèi)外醫(yī)院感染重大事件時有報道，不僅嚴(yán)重制約了醫(yī)療質(zhì)量的提升，干擾了醫(yī)院和

45、諧發(fā)展，也給患者就醫(yī)安全和疾病康復(fù)構(gòu)成重大威脅。因此，醫(yī)院感染問題正日益引起各級衛(wèi)生行政部門和醫(yī)院管理者的高度重視。根據(jù)醫(yī)院等級評審的統(tǒng)一部署，按照三級精神病醫(yī)院評審標(biāo)準(zhǔn)（2011年版）實(shí)施細(xì)則醫(yī)院感染管理與持續(xù)改進(jìn)要求，為進(jìn)一步完善我院醫(yī)院感染管理的各項工作，我院制定了醫(yī)院感染管理工作督查記錄薄，請各部門按要求認(rèn)真填寫。要求如下：一、每月由監(jiān)控醫(yī)生或監(jiān)控護(hù)士向科主任、科護(hù)士長匯報本病區(qū)醫(yī)院感染管理小組工作開展情況，總結(jié)取得的成績，分析存在問題，并注意查找原因，制定院感管理持續(xù)改進(jìn)措施并加以落實(shí)。于次月初在科內(nèi)會議進(jìn)行集中反饋。二、科主任、科護(hù)士長須檢查評估工作質(zhì)量，并簽署意見后簽名。三、醫(yī)院

46、感染管理科及上級檢查發(fā)現(xiàn)的問題也應(yīng)及時記錄。四、培訓(xùn)人員包括：新醫(yī)生，進(jìn)修醫(yī)生、病區(qū)醫(yī)務(wù)人員及工勤人員，可根據(jù)本部門實(shí)際，組織學(xué)習(xí)醫(yī)院感染、傳染病、抗菌素合理應(yīng)用等知識。 XXXXXX醫(yī)院醫(yī)院感染管理委員會本部門2017年度醫(yī)院感染監(jiān)控小組名單及職責(zé)時 間組長（科主任）小組成員副組長（科護(hù)士長）監(jiān)控醫(yī)生（區(qū)主任）監(jiān)控護(hù)士（區(qū)護(hù)士長）注：人員變動時應(yīng)做好交接班工作，及時記錄更換人員名單感染監(jiān)控小組職責(zé)各科室建立醫(yī)院感染管理小組，由科主任、護(hù)士長及本科室兼職監(jiān)控醫(yī)生（區(qū)主任）、護(hù)士（區(qū)護(hù)長）組成，在科主任領(lǐng)導(dǎo)下開展工作。其主要職責(zé)及工作內(nèi)容是：1、 在醫(yī)院感染管理科專職人員的業(yè)務(wù)指導(dǎo)下，負(fù)責(zé)本科室

47、醫(yī)院感染監(jiān)控工作。2、 監(jiān)督檢查本科室醫(yī)務(wù)人員嚴(yán)格執(zhí)行無菌操作技術(shù)并檢查無菌物品使用日期、無菌包名稱、滅菌指示卡、消毒日期等。3、 督促檢查本科室各種消毒隔離制度的落實(shí)情況、研究存在問題，并及時采取有效控制措施。4、 負(fù)責(zé)醫(yī)院感染的診斷把關(guān)，負(fù)責(zé)督促主管醫(yī)師及時填報醫(yī)院感染病例登記表、醫(yī)院感染病例登記本，定期分析本病區(qū)醫(yī)院感染動態(tài)，做好資料收集和上報工作。5、 指導(dǎo)本科室合理使用抗菌藥物，依據(jù)藥敏結(jié)果指導(dǎo)用藥，防止抗菌藥物的濫用。6、 可疑或發(fā)現(xiàn)醫(yī)院感染暴發(fā)流行時，主動查找原因及時向醫(yī)院感染管理科匯報，主動配合醫(yī)院感染專職人員進(jìn)行醫(yī)院感染暴發(fā)的流行病學(xué)調(diào)查，并采取有效控制措施。7、 負(fù)責(zé)本科室

48、預(yù)防和控制醫(yī)院感染的宣教培訓(xùn)工作。8、 嚴(yán)格消毒劑的使用管理，并做好相應(yīng)記錄。9、 負(fù)責(zé)本科室紫外線強(qiáng)度監(jiān)測及環(huán)境微生物監(jiān)測報告的收集留檔工作。10、 建立醫(yī)院感染管理記錄本，及時記錄本科室感染控制方面的問題、整改措施以及會議內(nèi)容，針對醫(yī)院感染管理工作中出現(xiàn)的問題，采取有效控制措施等。11、 配合醫(yī)院感染專職人員做好醫(yī)院感染目標(biāo)性監(jiān)測工作及其他臨時工作。醫(yī)院感染兼職醫(yī)師（區(qū)主任）職責(zé)1、 在科主任領(lǐng)導(dǎo)下，負(fù)責(zé)本病區(qū)感染管理工作。2、 負(fù)責(zé)對本病區(qū)工作人員進(jìn)行醫(yī)院感染知識的培訓(xùn)及宣教工作。3、 發(fā)現(xiàn)醫(yī)院感染病例或可疑醫(yī)院感染病例時，及時采樣做細(xì)菌培養(yǎng)、藥敏實(shí)驗(yàn)和其他必要的輔助檢查，協(xié)助主管醫(yī)生完

49、成感染病例的診斷。4、 執(zhí)行醫(yī)院感染病例監(jiān)測報告制度，發(fā)現(xiàn)醫(yī)院感染病例，督促主管醫(yī)生及時在醫(yī)生工作站填寫醫(yī)院感染病例登記表，24小時內(nèi)網(wǎng)上報醫(yī)院感染管理科，并填寫醫(yī)院感染病例登記本。5、 負(fù)責(zé)監(jiān)督本病區(qū)工作人員消毒隔離制度及無菌技術(shù)操作的落實(shí)情況，發(fā)現(xiàn)問題及時提出改進(jìn)措施。6、 監(jiān)督本病區(qū)工作人員醫(yī)療廢物分類存放情況，嚴(yán)禁生活廢物與醫(yī)療廢物混放，防止利器刺傷。7、 發(fā)生醫(yī)院感染流行趨勢或暴發(fā)流行時，立即向科主任及醫(yī)院感染管理科匯報，積極協(xié)助專職人員開展流行病學(xué)調(diào)查，查找感染原因，采取有效控制措施。8、 協(xié)助醫(yī)院感染專職人員開展醫(yī)院感染專題研究工作。9、 配合醫(yī)院感染專職人員做好醫(yī)院感染目標(biāo)性監(jiān)測工作及其他臨時工作。醫(yī)院感染兼職護(hù)師（區(qū)護(hù)長）職責(zé)1、 在科主任領(lǐng)導(dǎo)下，負(fù)責(zé)本病區(qū)醫(yī)院感染管理工作。2、 負(fù)責(zé)對本病區(qū)工作人員進(jìn)行感染知識培訓(xùn)及宣教工作。3、 負(fù)責(zé)監(jiān)督本病區(qū)工作人員消毒隔離及無菌技術(shù)操作的落實(shí)情況，發(fā)現(xiàn)問題及時提出改進(jìn)措施。4、 監(jiān)督本病區(qū)工作人員醫(yī)療廢物分類存放和登記情