院感制度.doc

医院管理制度(医院感染分册) 平遥县中医院 目录第一章概述 1. 医院感染管理体系····················································1 2. 医院感染管理委员会 3. 医院感染管理科 4. 临床医院感染管理小组····················································2 5. 医疗废物管理小组···················································3 第二章医院感染管理职责 6. 医院感染管理委员会职责············································4 7. 医院感染管理科职责·················································4 8. 医院感染管理科专职人员职责······································4 9. 医务科在医院感染管理工作中的职责······························5 10. 药剂科在医院感染管理工作中的职责······························5 11. 护理部在医院感染管理工作中的职责······························5 12. 总务科在医院感染管理工作中的职责·····························5 13. 检验科在医院感染管理工作中的职责····························5 14. 临床科室医院感染管理小组职责···································5 15. 医院感染监控医师职责··············································6 16. 医院感染监控护士职责··············································6 17. 医务人员在医院感染管理中的职责·································6 18. 医疗废物专职管理人员职责·····································35 19. 医疗废物专职收集运送人员职责··································36 第三章医院感染管理制度 20. 医院感染管理制度····················································7 21. 医院感染培训教育制度···············································7 23. 医院感染控制重点项目管理制度 24. 传染病管理制度·······················································8 25. 终末消毒制度·························································8 26. 医院感染消毒隔离制度··············································9 27. 一次性使用医疗器械、器具管理制度······················10 28. 消毒药械医院感染管理制度·········································10 29. 医疗器械及用品的消毒与灭菌管理制度 30. 常用物品的消毒与灭菌… 31. 外来器械管理制度 32. 植入物管理制度 33. 医院感染病例监测制度··············································11 34. 医院环境卫生学消毒、灭菌效果监测制度·························11 35. 紫外线灯管使用、监测管理制度····································12 36. 抗感染药物应用管理制度············································13 37. 多重耐药菌医院感染控制制度 38. 常见耐药菌感染病人的隔离措施… 39. 医务人员手卫生制度·················································13 40. 医务人员工作中时的一般防护······································14 41. 医务人员职业防护制度····