Sloppy management makes the great misfortune

Sloppy management makes the great misfortune
Sloppy management makes the great misfortune
Staff reporter Sun Meng At 30 past 21 on December 8, slightly showing in the rain, reporters reached Anhui Province Huoshan county together in company with the expert panel of Ministry of Public Health the cold night. It is introduced blood of hospital, county of Huoshan, the room is turn on to examine even completely the same day. But when the reporter reached this courtyard early in the morning on December 9, blood room think patient already completely, rectifying and improving the rail constructing puts up too. It is the room completely in the blood of this siheyuan occupied by a single family, have many persons of blood completely the patient is infected with third liver. Transfer to the open patient and increase to 19 The county hospital of Huoshan receives to a patient to now the reflection which is infected with third liver virus situation in the hospital of Huoshan county from November 26, third the intersection of liver and antibody transfer positive patient to, sift 16 people that announce to the outside rise to 19 people check, at first already during courtyard. Ministry of Public Health expert panel say until institute this increase 3 people examine, by oneself at first the figure. Its basis is that a blood specimen of a provincial medical inspection center of Anhui inspects by ready samples and reexamines the result: Drip degree and measure through third liver RNA, verifies that there is virus that is duplicated in these 3 human body, it is infective that that is to say to have. In fact, before the expert panel of Ministry of Public Health comes, the department of public health of Anhui Province, fitting the municipal and county hospital of Huoshan to infecting the incident to reply actively this time six times, and already organized the expert to investigate inside the province. On December 9, through collecting evidence intensely of one day, the expert panel of Ministry of Public Health draws the preliminary conclusion: This third liver antibody of this year for institute be lasted rates open being 32.8% every year,and it is operate and if you can't infect a great deal of in controlling, exchange by sense factor completely at blood not to synthesize by institute, characterize this incident as a infecting breaking out in the hospital incident finally. Among them, the managerial careless omission is the greatest inducement of this incident. While distributing new dispatchs up to the reporter, have originally already been transferred to and has fitted city the People's Hospital and fitted the municipal hospital of the city and carried on the blood, there is medical personnel every day in the hospital of Huoshan county to accompany and dialyse patients and travel to and fro between county, city. It is caused by any to sterilize and infect in the courtyard that the question is the hospital of Huoshan county of the largest inducement on earth? Ministry of Public Health expert panel say because blood room park, examine already completely at present, operate unable to reduce specifically, investigate that can only obtain the doubtful point from present scene and existing material. The reporter follows the expert panel of Ministry of Public Health and enters blood of this institute the room completely. The expert asks the head nurse to open a machine among them. In view of memory function of the machine, the disinfectant density of the dialysing machine has not reached and stipulated the requirement, and did not sterilize once averagely until 4 days every 3 days. Expert panel member, the intersection of Peking University and first hospital infect, manage the intersection of head of the department and Li, 600 million recommend, in this incident, it is the greatest hidden danger that measure of institute's sense prevention and control of sterilizing, isolating etc. is uncomplete. Expert panel learn through the intersection of hospital and the intersection of blood and talk of XueFei Tian, head nurse of centre, completely, county of Huoshan, in every two dialyse a patient, nurses do not sterilize the machine, and this is forbidden in blood strictly completely in institute's sense of the room is controlled. In addition, the nurse is not clear either to the method of testing of the antiseptic density. Another question met in the investigation is the hand hygiene. The reporter sees, 4 which dialyse the room are dialysed in one none washes the hand pool. Nurse claim from May of this year, blood room uses antiseptic of hand in unison completely, up till now, from 6 bottles of hands antiseptic of neck in the courtyard altogether. And expert statistics show, the base figure of dialysing 320 persons on average according to the moon which this institute offers is calculated, 6 bottle hand antiseptic ( 750 ml / bottle) Can't far meet the requirement of hand hygiene. In the investigation, the expert still finds this institute dialyses the patient to registers and can not record completely, rules and regulations can not require clearly, dialyse the overall arrangement of the room the unreasonable, medical worker protect and supervise the other questions incompletely,etc. inside and outside of sum uncompletely bidirectionally. Lee 600 million says, the formulation of the system must be pointed. For example, " strengthen and sterilize isolating " This kind of fuzziness requires that should be detailed and turns " Every two dialyse between the patient wanting, going on, sterilizing, wanting, taking to person who dialyse which kind of what is antiseptic, density of antiseptic " Wait for the effective clause. Supervise result why prominent Huoshan incident this year a blood is dialysed and infected third liver incident. Central hospital, worker's hospital of department and coal of Shanxi take place blood dialyse patient, infect third liver behind the incident from the beginning of this year the intersection of Shanxi and common to hand over to the collective Taiyuan, Ministry of Public Health requires regional health authorities to carry on the drawing in the net type to check in launching the medical organization completely of blood, and use " fly and check " Way go on superintend and check. The reporter learnt too in interview once, infected third liver incident in order to prevent the dialysis patient similar to Shanxi from then on, from April 1 this year, the hospital of Huoshan county stopped the replying and using of the dialysing device. Say, health authorities demand to rigorously enforce so, the hospital pays attention to very much too according to the reason, why did this kind of courtyard sense incident still remain incessant after repeated prohibition? The reporter hears a lot of local experts in Anhui say in the interview, if you want to reduce the blood and dialyse the hospital caused to infect to the greatest extent, must dialyse the upper and lower time of operation regulation in the blood. It is introduced, on the aspect of operating technology at present, the regulatory description of Ministry of Public Health " the blood dialysing device replies and uses the operation regulation " is more detailed. Anhui Province department of public health cure the intersection of policy and Lin Feng, vice section chief of, say blood of Anhui dialyse technological operation regulation for first draft, issue this guidance norm inside the province to already bring into schedule. In addition, it is very important to strengthen the relevant training of the personnel at the basic level too. Ministry of Public Health the intersection of expert panel and member, Peking University the intersection of the People's Hospital and blood the intersection of room and head nurse quick to say for example wingceltis have completely, this institute is after can reply and use the dialysing device to stop usinging, a lot of medical personnel thinks, the hospital where the blood dialysed has been infected with thereupon elimination too of the hidden danger. But in fact, that changed into disposable products is only the dialysis device even more, the disinfection of the dialysing machine can't be relaxed at all. Li 600 million show, rectify and improve, should pay attention to 3 levels to at the basic level training of person in a next one too. First, the training of the professional technique and knowledge of institute's sense prevention and control, second, the training of the personnel of infectious disease department of hospital completely to the blood, third, supervise the inspector's training to the outside.


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