2016年抗菌药物使用管理制度

2016年抗菌药物使用 管理制度 档案管理制度下载食品安全管理制度下载三类维修管理制度下载财务管理制度免费下载安全设施管理制度下载 顺庆区人民医院抗感染药物应用管理 制度 关于办公室下班关闭电源制度矿山事故隐患举报和奖励制度制度下载人事管理制度doc盘点制度下载 一、严格按照《医院抗感染药物使用管理规范》使用抗感染药物，力争将使用率控制在50%以下。 二、严格履行抗感染药物使用申报审批手续，凡越级使用抗感染药物或联合用药，必须填写审批表，科主任批准并报药事科备案。 三、加强抗感染药物使用的组织管理，成立药事管理委员会，全面负责抗感染药物管理和相关工作的具体实施管理。 四、成立由药剂科、感染管理科、检验科组成的临床药物管理小组，负责科室抗感染药物管理及药物不良反应监测并定期总结通报相关情况，定期向全院提供院内抗生素使用情况。 五、完善抗感染药物使用的制度措施，制订适合本院实际的具体的感染药物使用范围、使用细则、考核指标、管理要求，明确抗感染药三线划分目录和三级医师使用抗感染药物的权限。建立抗感染药物使用管理责任制，明确职责、认真贯彻落实。 六、临床各级医护人员必须接受抗感染药物合理使用规范培训，并纳入继续教育学习范围。 七、参与药事管理委员会的抗感染药物专家应是有经验的医师，负责指导全院抗感染药物的应用。 八、检验科和药事科定期公布主要致病菌及其药敏试验结果，向临床医生提供抗感染药物信息，为合理使用抗感染药物提供依据。 九、临床医生应提高用药前相关标本的送检率，根据细菌培养和药敏for more than 60 years of rural senior party member care funds; System of regulating the activities of grass-roots party organizations, and enhance the sense of belonging of grass-roots party members; Hold fast to implement "red credit", "red stake" two major project opportunities, strive to explore new ways of development of village collective economy, rural collective economy achieve breakthrough; A progress review by the Secretary of the party work of grass-roots party organizations, strengthens the responsibility of grasping party building, Party Secretary. Second, strengthening the construction of clean and honest Government and fight against corruption. Seriously implement the honest responsibility, actively carry out the independent Commission against corruption interview system, increase the leadership and the day-to-day supervision of party members and cadres at all levels, strengthen the not Winds of special treatment, treatment of "laid-back luxury and arrogance" and "three-pronged" problem, non-gang, national public officers, serving in leadership positions is not land, above-standard equipped with buses and cars for private purposes, and recreational city of gifts, hospitality, luxury and waste, "emptied the rating" special rectification work. Adhere to the rot will be punishing, corrupt Su, and 1 village, 4 disciplinary administrative cadres and workers. Three is to strengthen peace to create a work. Strengthen source management, adhere to prevention, focusing on prevention. Carry out the "big reception, big tour" campaign, petitioning for the cadres of the 试验结果，严格掌握适应症，合理选用药物。护士配合医生做好各种标本留取和送检工作。 顺庆区人民医院手卫生制度 一、医务人员应严格执行卫生部下发的《手卫生规范》，诊疗活动时必须认真按照“六步洗手法”清洁或消毒双手;手术人员应执行外科手消毒方法。 二、在下列情况下，医务人员应选择洗手或使用速干手消毒剂消毒: 1、直接接触每个患者前后;从同一患者身体的污染部位移动到清洁部位时。 2、接触患者黏膜、破损皮肤或伤口前后;接触患者的血液、体液、分泌物、排泄物、伤口敷料等之后。 3、穿脱隔离衣前后，摘手套后。 4、进行无菌操作、接触清洁、无菌物品之前。 5、接触患者周围环境及物品后。 6、处理药物或配餐前。 三、当手部有血液或体液等肉眼可见污染时，应用洗手液和流动水洗手。手部无可见污染物时，可用速干手消毒剂消毒双手代替洗手。 for more than 60 years of rural senior party member care funds; System of regulating the activities of grass-roots party organizations, and enhance the sense of belonging of grass-roots party members; Hold fast to implement "red credit", "red stake" two major project opportunities, strive to explore new ways of development of village collective economy, rural collective economy achieve breakthrough; A progress review by the Secretary of the party work of grass-roots party organizations, strengthens the responsibility of grasping party building, Party Secretary. Second, strengthening the construction of clean and honest Government and fight against corruption. Seriously implement the honest responsibility, actively carry out the independent Commission against corruption interview system, increase the leadership and the day-to-day supervision of party members and cadres at all levels, strengthen the not Winds of special treatment, treatment of "laid-back luxury and arrogance" and "three-pronged" problem, non-gang, national public officers, serving in leadership positions is not land, above-standard equipped with buses and cars for private purposes, and recreational city of gifts, hospitality, luxury and waste, "emptied the rating" special rectification work. Adhere to the rot will be punishing, corrupt Su, and 1 village, 4 disciplinary administrative cadres and workers. Three is to strengthen peace to create a work. Strengthen source management, adhere to prevention, focusing on prevention. Carry out the "big reception, big tour" campaign, petitioning for the cadres of the 四、医务人员手被传染性物质污染以及直接为传染病病人进行检查、治疗、护理或处理传染病病人污染物之后，应当先用洗手液和流动水冲净，然后进行卫生手消毒。 五、各科室应配备合格的手卫生设备和设施。重点部门如重症监护室、新生儿病室、血透室、感染疾病科、手术室、产房、导管室、消毒供应中心、口腔科、内镜室、烧伤病房、检验科等应安装非手触式水龙头开关，配备洗手液及干手设施(避免造成二次污染)。 六、手术室应制定外科手消毒流程，并督促执行。 七、外科手消毒的原则，应遵循先洗手，后消毒，不同患者手术之间等应重新进行外科手消毒。 八、外科手消毒应遵循卫生部下发的《手卫生规范》注意事项及要求。 九、院感科加强对医务人员手卫生工作指导与监督，随时进行洗手时机的抽查，每月对手卫生一次性进行调查并总结，每季度对重点部门进行手卫生消毒效果的监测，当怀疑暴发与医务人员手有关时，及时进行监测。 十、开展医务人员手卫生知识培训，掌握正确的手卫生方法，保证洗手与手消毒效果，提高医务人员手卫生的依从性。 for more than 60 years of rural senior party member care funds; System of regulating the activities of grass-roots party organizations, and enhance the sense of belonging of grass-roots party members; Hold fast to implement "red credit", "red stake" two major project opportunities, strive to explore new ways of development of village collective economy, rural collective economy achieve breakthrough; A progress review by the Secretary of the party work of grass-roots party organizations, strengthens the responsibility of grasping party building, Party Secretary. Second, strengthening the construction of clean and honest Government and fight against corruption. Seriously implement the honest responsibility, actively carry out the independent Commission against corruption interview system, increase the leadership and the day-to-day supervision of party members and cadres at all levels, strengthen the not Winds of special treatment, treatment of "laid-back luxury and arrogance" and "three-pronged" problem, non-gang, national public officers, serving in leadership positions is not land, above-standard equipped with buses and cars for private purposes, and recreational city of gifts, hospitality, luxury and waste, "emptied the rating" special rectification work. Adhere to the rot will be punishing, corrupt Su, and 1 village, 4 disciplinary administrative cadres and workers. Three is to strengthen peace to create a work. Strengthen source management, adhere to prevention, focusing on prevention. Carry out the "big reception, big tour" campaign, petitioning for the cadres of the 顺庆区人民医院医疗器具消毒管理制度 一、医院应建立消毒管理组织，制定消毒管理制度，执行国家有关规范、 标准 excel标准偏差excel标准偏差函数exl标准差函数国标检验抽样标准表免费下载红头文件格式标准下载 和 规定 关于下班后关闭电源的规定党章中关于入党时间的规定公务员考核规定下载规定办法文件下载宁波关于闷顶的规定 ，定期开展消毒与灭菌效果检测。 二、医院工作人员应当接受消毒技术培训、掌握消毒知识，并按规定严格执行消毒隔离制度。 三、医院使用的进入人体组织或无菌器官的医疗用品必须达到灭菌要求。各种注射、穿刺、采血器具应当一人一用一灭菌。凡接触皮肤、粘膜的器械和用品必须达到消毒要求。 四、医院使用的一次性使用医疗用品用后应当及时进行分类收集并送指定部门进行处理。 五、医院购进消毒产品必须建立并执行进货检查验收制度。 六、医疗卫生机构的环境、物品应当符合国家有关规范、标准和规定。七、排放废弃的污水、污物应当按照国家有关规定进行无害化处理。八、运送传染病病人及其污染物品的车辆、工具必须随时进行消毒处理。 九、医疗卫生机构发生感染性疾病暴发、流行时，应当及时报告当地疾病控制中心和卫生行政部门，并采取有效消毒措施。 for more than 60 years of rural senior party member care funds; System of regulating the activities of grass-roots party organizations, and enhance the sense of belonging of grass-roots party members; Hold fast to implement "red credit", "red stake" two major project opportunities, strive to explore new ways of development of village collective economy, rural collective economy achieve breakthrough; A progress review by the Secretary of the party work of grass-roots party organizations, strengthens the responsibility of grasping party building, Party Secretary. Second, strengthening the construction of clean and honest Government and fight against corruption. Seriously implement the honest responsibility, actively carry out the independent Commission against corruption interview system, increase the leadership and the day-to-day supervision of party members and cadres at all levels, strengthen the not Winds of special treatment, treatment of "laid-back luxury and arrogance" and "three-pronged" problem, non-gang, national public officers, serving in leadership positions is not land, above-standard equipped with buses and cars for private purposes, and recreational city of gifts, hospitality, luxury and waste, "emptied the rating" special rectification work. Adhere to the rot will be punishing, corrupt Su, and 1 village, 4 disciplinary administrative cadres and workers. Three is to strengthen peace to create a work. Strengthen source management, adhere to prevention, focusing on prevention. Carry out the "big reception, big tour" campaign, petitioning for the cadres of the 顺庆区人民医院医务人员血(体)液 职业暴露防护措施 医务人员血(体)液职业暴露是医务人员从事诊疗、实验、护理工作中意外被乙肝、丙肝、艾滋病等病毒感染者的血液、体液污染了皮肤、粘膜，或者是被污染的针头及其它锐器刺破皮肤，有可能被病毒感染的情况。 一、医务人员的防护措施应当遵照标准预防原则，对所有病人的血液、体液及被血液、体液污染的物品均视为具有传染性的病源物质，医务人员接触这些物质时，必须采用预防措施。任何医务人员发生血液、体液职业暴露(刺伤、割伤、粘膜接触等)，应迅速报告院感办(电话2250880)。 二、院感办应迅速了解患者情况、发生职业暴露的经过，指导医护人员填好血(体)液职业暴露个案登记表。对发生职业暴露风险较大的情况，在诊治前应对患者进行相关检测。 三、输血科发现,，,初筛阳性患者，应立即通知临床科室、与区疾病预防控制中心联系进行确诊检测，并负责及时得到确诊报告 四、医务人员在进行侵袭性诊疗、护理、实验操作过程中，要保证充足的光线，并特别注意防止被针头、缝合针、刀片等锐器刺伤或划伤。 五、禁止将使用后的一次性针头双手重新盖帽，如需盖帽只能用单手盖帽，禁止用手直接接触污染的针头、刀片等锐器。 六、手术中传递锐器建议使用传递容器，以免损伤医务人员。 for more than 60 years of rural senior party member care funds; System of regulating the activities of grass-roots party organizations, and enhance the sense of belonging of grass-roots party members; Hold fast to implement "red credit", "red stake" two major project opportunities, strive to explore new ways of development of village collective economy, rural collective economy achieve breakthrough; A progress review by the Secretary of the party work of grass-roots party organizations, strengthens the responsibility of grasping party building, Party Secretary. Second, strengthening the construction of clean and honest Government and fight against corruption. Seriously implement the honest responsibility, actively carry out the independent Commission against corruption interview system, increase the leadership and the day-to-day supervision of party members and cadres at all levels, strengthen the not Winds of special treatment, treatment of "laid-back luxury and arrogance" and "three-pronged" problem, non-gang, national public officers, serving in leadership positions is not land, above-standard equipped with buses and cars for private purposes, and recreational city of gifts, hospitality, luxury and waste, "emptied the rating" special rectification work. Adhere to the rot will be punishing, corrupt Su, and 1 village, 4 disciplinary administrative cadres and workers. Three is to strengthen peace to create a work. Strengthen source management, adhere to prevention, focusing on prevention. Carry out the "big reception, big tour" campaign, petitioning for the cadres of the 七、使用后的锐器应当直接放入耐刺、防渗透的利器盒中，以防刺伤。 八、医务人员进行有可能接触病人血液、体液的诊疗、护理和实验操作时必须戴手套，操作完毕，脱去手套后立即洗手或进行手消毒。 九、在诊疗、护理、实验操作过程中，有可能发生血液、体液飞溅到医务人员的面部时，医务人员应当戴口罩、防护眼镜;有可能发生血液、体液大面积飞溅或者有可能污染医务人员的身体时，还应当穿戴具有防渗透性能的隔离衣或者围裙。 十、处理污物时严禁用手直接抓取污物，尤其是不能将手伸入到垃圾袋中向下压挤废物，以免被锐器刺伤。 顺庆区人民医院治疗室的消毒隔离工作制 度 一、治疗室布局合理，专人负责，严格区分有菌区与无菌区、清洁区与污染区，并有明显标记，进入治疗室人员必须衣帽整齐，操作前应洗手戴口罩、凡私人用物不得带进治疗室。 二、严格执行《无菌技术操作 规程 煤矿测量规程下载煤矿测量规程下载配电网检修规程下载地籍调查规程pdf稳定性研究规程下载 》，无菌物品按灭菌日期依次放入无菌柜内，不得有过期物品。治疗室无菌物品与非无菌物品，严格分开放置。使用无菌物品时，应严格执行无菌操作原则。 三、治疗室应湿式清扫，清扫物品要专用，每日通风，并用三氧消for more than 60 years of rural senior party member care funds; System of regulating the activities of grass-roots party organizations, and enhance the sense of belonging of grass-roots party members; Hold fast to implement "red credit", "red stake" two major project opportunities, strive to explore new ways of development of village collective economy, rural collective economy achieve breakthrough; A progress review by the Secretary of the party work of grass-roots party organizations, strengthens the responsibility of grasping party building, Party Secretary. Second, strengthening the construction of clean and honest Government and fight against corruption. Seriously implement the honest responsibility, actively carry out the independent Commission against corruption interview system, increase the leadership and the day-to-day supervision of party members and cadres at all levels, strengthen the not Winds of special treatment, treatment of "laid-back luxury and arrogance" and "three-pronged" problem, non-gang, national public officers, serving in leadership positions is not land, above-standard equipped with buses and cars for private purposes, and recreational city of gifts, hospitality, luxury and waste, "emptied the rating" special rectification work. Adhere to the rot will be punishing, corrupt Su, and 1 village, 4 disciplinary administrative cadres and workers. Three is to strengthen peace to create a work. Strengthen source management, adhere to prevention, focusing on prevention. Carry out the "big reception, big tour" campaign, petitioning for the cadres of the 毒机进行空气消毒。 四、治疗室每日清扫、消毒一次，每周更换大消毒二次，并注明消毒日期。 五、各种治疗注射应一人一针一管一带(含皮试)，用后针头、针管及一次性输液器放等应分类放置，由专职人员统一处理。 六、取用无菌物品时，必须用无菌持物钳或无菌镊子，镊子与消毒容器应配套使用，一容器一器械，并浸泡在1/2,2/3处，定期更换、消毒，并注明日期。 七、一次性医疗用品按《一次性医疗用品管理制度》管理，一次性用品必须去除外包装后方可进入治疗室。 八、抽出的药液，开启的静脉输入用无菌液体须注明时间，超过2小时后不得使用;启封抽吸的各种溶酶超过24小时不得使用。 九、医疗废物分类收集，日产日清，医疗废物专用容器包装严密，标示清楚，交接记录存档。 十、医护人员严格执行《医务人员手卫生规范》。 for more than 60 years of rural senior party member care funds; System of regulating the activities of grass-roots party organizations, and enhance the sense of belonging of grass-roots party members; Hold fast to implement "red credit", "red stake" two major project opportunities, strive to explore new ways of development of village collective economy, rural collective economy achieve breakthrough; A progress review by the Secretary of the party work of grass-roots party organizations, strengthens the responsibility of grasping party building, Party Secretary. Second, strengthening the construction of clean and honest Government and fight against corruption. Seriously implement the honest responsibility, actively carry out the independent Commission against corruption interview system, increase the leadership and the day-to-day supervision of party members and cadres at all levels, strengthen the not Winds of special treatment, treatment of "laid-back luxury and arrogance" and "three-pronged" problem, non-gang, national public officers, serving in leadership positions is not land, above-standard equipped with buses and cars for private purposes, and recreational city of gifts, hospitality, luxury and waste, "emptied the rating" special rectification work. Adhere to the rot will be punishing, corrupt Su, and 1 village, 4 disciplinary administrative cadres and workers. Three is to strengthen peace to create a work. Strengthen source management, adhere to prevention, focusing on prevention. Carry out the "big reception, big tour" campaign, petitioning for the cadres of the