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院感制度.
医院管理制度
（医院感染分册）
平遥县中医院
2011.5
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
22.医院感染管理会议制度
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·························
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