JOINT

COMMISSION

INTERNATIONAL

ACCREDITATION

STANDARDS

FOR

HOSPITALS,

4TH

EDITION

美國醫(yī)療機(jī)構(gòu)評審國際聯(lián)合委員會

國際醫(yī)院管理標(biāo)準(zhǔn)

（第四版）

（2011年1月1日起執(zhí)行）Section

I:

Patient-Centered

Standards

患者中心標(biāo)準(zhǔn)International

Patient

Safety

Goals

(IPSG)國際患者安全目標(biāo)Access

to

Care

and

Continuity

of

Care

(ACC)醫(yī)療護(hù)理途徑及連續(xù)性Patient

and

Family

Rights

(PFR)患者及其家屬權(quán)益Assessment

of

Patients

(AOP)患者評估Care

of

Patients

(COP)患者的醫(yī)療護(hù)理Anesthesia

and

Surgical

Care

(ASC)麻醉及外科醫(yī)療護(hù)理Medication

Management

and

Use

(MMU)藥品管理和使用Patient

and

Family

Education

(PFE)患者及其家屬教育International

Patient

Safety

Goals

(IPSG)

國際患者安全目標(biāo)IPSG.1

Identify

Patients

CorrectlyIPSG.2

Improve

Effective

CommunicationIPSG.3

Improve

the

Safety

of

High-Alert

MedicationsIPSG.4

Ensure

Correct-Site,

Correct-Procedure,

Correct-Patient

SurgeryIPSG.5

Reduce

the

Risk

of

Health

Care–Associated

InfectionsIPSG.6

Reduce

the

Risk

of

Patient

Harm

Resulting

from

FallsInternational

Patient

Safety

Goals

(IPSG)

國際患者安全目標(biāo)IPSG.1

正確辨認(rèn)患者

IPSG.2

有效地改進(jìn)溝通

IPSG.3

改進(jìn)高敏感性療程的安全性IPSG.4

保證正確部位，正確做法，正確患者手術(shù)IPSG.5

減少相關(guān)醫(yī)療風(fēng)險IPSG.6

減少患者摔倒發(fā)生傷害的風(fēng)險

Access

to

Care

and

Continuity

of

Care

(ACC)

醫(yī)療護(hù)理途徑及連續(xù)性ACC.1

Patients

are

admitted

to

receive

inpatient

care

or

registered

for

outpatient

services

based

on

their

identified

health

care

needsand

the

organization’s

mission

and

resources.ACC.2

The

organization

designs

and

carries

out

processes

to

provide

continuity

of

patient

care

services

inthe

organization

and

coordination

among

health

care

practitioners.ACC.3

There

is

a

policy

guiding

the

referral

or

discharge

of

patients.ACC.4

Patients

are

transferred

to

other

organizations

based

on

status

and

the

need

to

meet

their

continuingcare

needs.ACC.5

The

process

for

referring,

transferring,

or

discharging

patients,

both

inpatients

and

outpatients,includes

planning

to

meet

the

patient's

transportation

needs.Access

to

Care

and

Continuity

of

Care

(ACC)

醫(yī)療護(hù)理途徑及連續(xù)性ACC.1

根據(jù)患者治療需求和醫(yī)院使命及資源，決定患者住院治療或門診治療ACC.2

在醫(yī)院科室和醫(yī)護(hù)人員間制定并實(shí)施相互協(xié)調(diào)的程序，為患者提供連續(xù)的醫(yī)療服務(wù)ACC.3

指導(dǎo)患者轉(zhuǎn)診或出院的制度明確ACC.4

根據(jù)病情和需要，為讓患者得到持續(xù)治療，有患者轉(zhuǎn)院制度ACC.5

住院和門診患者的轉(zhuǎn)診、轉(zhuǎn)院，或出院程序含有患者運(yùn)送需求的計(jì)劃Patient

and

Family

Rights

(PFR)

患者及其家屬權(quán)益PFR.1

The

organization

is

responsible

for

providing

processes

that

support

patients’

and

families’

rightsduring

care.PFR.2

The

organization

supports

patients’

and

families’

rights

to

participate

in

the

care

process.PFR.3

The

organization

informs

patients

and

families

about

its

process

to

receive

and

to

act

on

complaints,

conflicts,

and

differences

of

opinion

about

patient

care

and

the

patient’s

right

to

participate

in

theseprocesses.PFR.4

Staff

members

are

educated

about

their

roles

in

identifying

patients’

values

and

beliefs

and

protecting

patients’

rights.PFR.5

All

patients

are

informed

about

their

rights

and

responsibilities

in

a

manner

and

language

they

canunderstand.PFR.6

Patient

informed

consent

is

obtained

through

a

process

defined

by

the

organization

and

carried

out

by

trained

staff

in

a

language

the

patient

can

understand.Patient

and

Family

Rights

(PFR)

患者及其家屬權(quán)益PFR.1

醫(yī)院負(fù)責(zé)提供支持患者及其家屬在治療期間權(quán)益的程序PFR.2

醫(yī)院支持患者及其家屬參與治療過程的權(quán)益PFR.3

醫(yī)院告知患者及其家屬有關(guān)受理投訴、糾風(fēng)和不同治療意見的程序，及參與這些程序的權(quán)益PFR.4

教育員工正確對待不同價值觀和信仰的患者，并維護(hù)其權(quán)益PFR.5

以患者能理解的方式和語言告知其權(quán)益和責(zé)任PFR.6

用患者能理解的語言訓(xùn)煉員工，并由其通過醫(yī)院制定的程序獲得患者知情同意Patient

and

Family

Rights

(PFR)

患者及其家屬權(quán)益PFR.7

The

organization

informs

patients

and

families

about

how

to

gain

access

to

clinical

research,

clinical

investigation,

or

clinical

trials

involving

human

subjects.PFR.8

Informed

consent

is

obtained

before

a

patient

participates

in

clinical

research,

clinical

investigation,and

clinical

trials.PFR.9

The

organization

has

a

committee

or

another

way

to

oversee

all

research

in

the

organization

involving

human

subjects.PFR.10

The

organization

informs

patients

and

families

about

how

to

choose

to

donate

organs

and

other

tissues.PFR.11

The

organization

provides

oversight

of

the

harvesting

and

transplantation

of

organs

and

tissues.Patient

and

Family

Rights

(PFR)

患者及其家屬權(quán)益PFR.7

醫(yī)院告知患者及其家屬有關(guān)如何獲得以人體為對象的臨床研究、監(jiān)床調(diào)查和臨床試驗(yàn)的途經(jīng)PFR.8

在患者參與臨床研究、臨床調(diào)查和臨床試驗(yàn)前，獲得患者知情同意PFR.9

醫(yī)院有一個委員會或其他方式監(jiān)督院內(nèi)所有以人體為對象的研究PFR.10

醫(yī)院告知患者及其家屬有關(guān)如何選擇捐獻(xiàn)人體器官和其他人體組織PFR.11

醫(yī)院監(jiān)督獲取和移植人體器官或組織Assessment

of

Patients

(AOP)

患者評估AOP.1

All

patients

cared

for

by

the

organization

have

their

health

care

needs

identified

through

an

established

assessment

process.AOP.2

All

patients

are

reassessed

at

intervals

based

on

their

condition

and

treatment

to

determine

their

response

to

treatment

and

to

plan

for

continued

treatment

or

discharge.AOP.3

Qualified

individuals

conduct

the

assessments

and

reassessments.AOP.4

Physicians,

nurses,

and

other

individuals

and

services

responsible

for

patient

care

collaborate

to

analyze

and

to

integrate

patient

assessments.AOP.5

Laboratory

services

are

available

to

meet

patient

needs,

and

all

such

services

meet

applicable

local

and

national

standards,

laws,

and

regulations.AOP.6

Radiology

and

diagnostic

imaging

services

are

available

to

meet

patient

needs,

and

all

such

services

meet

applicable

local

and

national

standards,

laws,

and

regulations.Assessment

of

Patients

(AOP)

患者評估AOP.1

通過已建立的評估程序，醫(yī)院確定了所有患者的醫(yī)療需求AOP.2

根據(jù)情況和治療需要，在一定間隔時間內(nèi)對所有患者進(jìn)行再評估，觀察他們對治療的反應(yīng)，制定持續(xù)治療或出院計(jì)劃AOP.3

由有資質(zhì)的人員指揮評估和再評估AOP.4

醫(yī)師、護(hù)士和其他負(fù)責(zé)患者治療的人員及科室共同分析和歸納患者評估AOP.5

所有實(shí)驗(yàn)室服務(wù)能有效地滿足患者需要，并符合當(dāng)?shù)睾蛧覙?biāo)準(zhǔn)、法律及法規(guī)AOP.6

所有放射和影像服務(wù)能有效地滿足患者需要，并符合當(dāng)?shù)睾蛧覙?biāo)準(zhǔn)、法律及法規(guī)Care

of

Patients

(COP)

患者的醫(yī)療護(hù)理COP.1

Policies

and

procedures

and

applicable

laws

and

regulations

guide

the

uniform

care

of

all

patients.COP.2

There

is

a

process

to

integrate

and

to

coordinate

the

care

provided

to

each

patient.COP.3

Policies

and

procedures

guide

the

care

of

highrisk

patients

and

the

provision

of

high-risk

services.COP.4

A

variety

of

food

choices,

appropriate

for

the

patient’s

nutritional

status

and

consistent

with

his

or

her

clinical

care,

is

regularly

available.COP.5

Patients

at

nutrition

risk

receive

nutrition

therapy.COP.6

Patients

are

supported

in

managing

pain

effectively.COP.7

The

organization

addresses

end-of-life

care.Care

of

Patients

(COP)

患者的醫(yī)療護(hù)理COP.1

治療規(guī)范，并符合政策、程序及有關(guān)法律和法規(guī)COP.2

對每位患者提供的治療有一個集成和協(xié)調(diào)的程序COP.3

高?；颊叩闹委熍c高危服務(wù)的提供符合政策、程序COP.4

各種各樣的食物選擇規(guī)范有效，符合患者營養(yǎng)狀況，并與臨床治療一致COP.5

有營養(yǎng)風(fēng)險的患者接受營養(yǎng)治療COP.6

支持患者有效地管理疼通COP.7

醫(yī)院提供臨終關(guān)懷治療AnesthesiaandSurgicalCare(ASC)

麻醉和外科治療ASC.1Anesthesiaservices(includingmoderateanddeepsedation)areavailabletomeetpatientneeds,andallsuchservicesmeetapplicablelocalandnationalstandards,laws,andregulationsandprofessionalstandards.ASC.2Aqualifiedindividual(s)isresponsibleformanagingtheanesthesiaservices(includingmoderateanddeepsedation).ASC.3Policiesandproceduresguidethecareofpatientsundergoingmoderateanddeepsedation.ASC.4Aqualifiedindividualconductsapreanesthesiaassessmentandpreinductionassessment.AnesthesiaandSurgicalCare(ASC)

麻醉和外科治療ASC.1所有麻醉服務(wù)（包括中度和深度鎮(zhèn)靜）滿足患者需求，并符合當(dāng)?shù)睾蛧覙?biāo)準(zhǔn)、法律、法規(guī)和專業(yè)標(biāo)準(zhǔn)ASC.2由有資質(zhì)的人員負(fù)責(zé)管理麻醉服務(wù)（包括中度和深度鎮(zhèn)靜）ASC.3政策和程序指導(dǎo)患者接受中度及深度鎮(zhèn)靜治療ASC.4由有資質(zhì)的人員指導(dǎo)麻醉前評估和正式手術(shù)前評估AnesthesiaandSurgicalCare(ASC)

麻醉和外科治療ASC.5Eachpatient’sanesthesiacareisplannedanddocumentedinthepatient’srecord.ASC.6Eachpatient’spostanesthesiastatusismonitoredanddocumented,andthepatientisdischargedfromtherecoveryareabyaqualifiedindividualorbyusingestablishedcriteria.ASC.7Eachpatient’ssurgicalcareisplannedanddocumentedbasedontheresultsoftheassessment.AnesthesiaandSurgicalCare(ASC)

麻醉和外科治療ASC.5在患者病歷中，有每位患者的麻醉治療計(jì)劃和紀(jì)錄ASC.6監(jiān)測和紀(jì)錄每位患者麻醉的狀態(tài)，由有資質(zhì)的人員，或按已建立的標(biāo)準(zhǔn)批準(zhǔn)患者離開恢復(fù)區(qū)ASC.7根據(jù)評估結(jié)果制定每位患者的外科治療計(jì)劃，并紀(jì)錄在案MedicationManagementandUse(MMU)

藥品管理和使用MMU.1Medicationuseintheorganizationcomplieswithapplicablelawsandregulationsandisorganizedtomeetpatientneeds.MMU.2Anappropriateselectionofmedicationsforprescribingororderingisstockedorreadilyavailable.MMU.3Medicationsareproperlyandsafelystored.MMU.4Prescribing,ordering,andtranscribingareguidedbypoliciesandprocedures.MMU.5Medicationsarepreparedanddispensedinasafeandcleanenvironment.MMU.6Theorganizationidentifiesthosequalifiedindividualspermittedtoadministermedications.MMU.7Medicationeffectsonpatientsaremonitored.MedicationManagementandUse(MMU)

藥品管理和使用MMU.1醫(yī)院用藥符合法律法規(guī)，并有效地滿足患者需求MMU.2規(guī)定或醫(yī)囑藥品的選擇庫存可用MMU.3正確、安全貯存藥品MMU.4按政策和程序開處方、下醫(yī)囑和抄錄用藥MMU.5在安全和清潔環(huán)境下準(zhǔn)備、分發(fā)藥品MMU.6醫(yī)院只允許有資質(zhì)的人員執(zhí)行用藥MMU.7監(jiān)控患者用藥療效Pat海ien扶ta孤nd洞Fam答ily續(xù)Ed梁uca右tio狗n(醫(yī)PFE漏)患者和垂家屬教望育PFE.探1T老heo堤rgan僚izat罩ion避prov托ides板edu哪cati走ont框hat載supp薄orts涌pat捷ient達(dá)and葬fam列ily洗part框icip察atio尋nin依car言ede店cisi個ons披and扯care叛pro興cess陵es.PFE彼.2居Ea廣ch朝pat語ien尿t’s捎ed顫uca像tio語nal確ne距eds掏ar飄ea符sse稅sse蔬da糊nd賊rec疾ord桌ed肅in液his蓄or懼he蛙rr砌eco旱rd.PFE彈.3搶Ed懸uca遵tio片na疤nd盲tra縫ini催ng踏hel通pm拖eet洗pa舒tie蘆nts煤’o鉛ngo雜ing棵he躺alt逃hn較eed留s.PFE界.4子Pa逝tie面nt揚(yáng)and閱fa謀mil碎ye躍duc躺ati屑o(jì)n芝inc什lud羊es咸the線fo驗(yàn)llo鏟win痛gt襯opi臂cs,罩re臉lat己ed食to般the援pa溪tie突nt’摸sc筐are澆:t松he妙saf尊eu如se驚of斑med撫ica果tio濁ns,援th海es倚afe貌us嫌eo箏fm勉edi練cal蹦eq梅uip話men市t,止pot胞ent滲ial干in甘ter慌act虜ion清sb批etw之een廉me終dic板ati艇ons遠(yuǎn)an繳df躍ood朗,n臨utr忠iti診ona畜lg槍uid伴anc喊e,訓(xùn)pai勒nm臺ana礦gem纏ent強(qiáng),a春nd崇reh侮abi蠻lit架ati普on西tec誓hni怕que鴉s.PFE魚.5薯Ed珠uca坊tio押nm壟eth荒ods杠in椅clu薪de污the遭pa弱tie越nt’休sa絮nd產(chǎn)fam錫ily蛾’s鄭val課ues朱an驗(yàn)dp侵ref倒ere謀nce認(rèn)sa泥nd育all旅ow冊suf佳fic桂ien鴉ti評nte帖rac靜tio賄na現(xiàn)mon繁gt霧he奧pat歇ien羊t,聞fam殺ily陳,a調(diào)nd忠sta冤ff級for魔le縫arn京ing嶄to唯oc覽cur撒.PFE.檢6He姥a(bǔ)lth糠pro喉fess慈iona罰lsc踏arin欲gfo揮rth庭epa兔tien嘆tco神llab襯orat朗eto惡pro旗vide矮edu潤cati藍(lán)on.Pat逗ien走ta移nd激Fam何ily融Ed汽uca離tio串n(晌PFE段)患者和潔家屬教飾育PFE.遇1醫(yī)穩(wěn)院提供教寫育支持患憶者和家屬警參與治療單決策及治男療過程PFE.凍2評睜估每位患諒者的教育倒需求，并資記入病歷PFE版.3搜教育若與訓(xùn)煉儲有助于牽滿足患評者持續(xù)渣健康需慢求PFE.交4患沙者和家屬請教育包括份下列患者英治療的相挖關(guān)題目：孟安全用藥圣、安全使缺用醫(yī)療設(shè)扔備、藥品鉤與食物間敬的潛在相粉互作用、雀營養(yǎng)指導(dǎo)誦、疼通管吵理，及康惜復(fù)技術(shù)PFE零.5悠教育英方法包率括患者驗(yàn)和家屬哪的價值蔬觀和特賢選需求膝，并允容許患者撥、家屬胡和員工斗在學(xué)習(xí)看上充足遵地交流PFE.大6為患伏者治療的禽醫(yī)護(hù)人員齡配合提供瓜教育Sect謠ion羨II:股Hea嫁lth草Car即eOr狐gani悟zati赴onM溪anag謙emen狗tS彈tand核ards濱醫(yī)療機(jī)柴構(gòu)管理標(biāo)銹準(zhǔn)Qua稀lit妻yI符mpr弊o(hù)ve廳men雪ta言nd蠻Pat污ien震tS礎(chǔ)afe罩ty黎(QP燥S)質(zhì)量改升進(jìn)與患邁者安全Prev示enti蓮ona犁ndC返ontr膽olo丑fIn醋fect習(xí)ions劉(PC薪I)感染預(yù)御防與控?cái)?shù)制Gov說ern目anc后e,玻Lea哨der捉shi涌p,筒and臭Di傾rec臨tio助n(開GLD報(bào))政府、懇領(lǐng)導(dǎo)和漆向?qū)ac彎ili企ty舅Man街age柴men恐ta桂nd衛(wèi)Saf舒ety膏(F莊MS)設(shè)施管壁理和安狡全Sta六ff疏Qua止lif得ica復(fù)tio增ns般and玩Ed斧uca派tio捆n(湊SQE歷)員工資培格與教洋育Mana焦geme聚nto相fCo籍mmun肯icat按ion眨and帆I(xiàn)nfo脆rmat壺ion巾(MCI址)溝通與逼情報(bào)管改理Qua陷lit老yI顆mpr腥ove忙men躍ta腸nd褲Pat錢ien快tS憤afe吃ty具(QP嗽S)原質(zhì)量改慣進(jìn)與患您者安全QPS粗.1千Th敗ose榆re略spo雄nsi藍(lán)ble誼fo鈔rg奶ove明rni債ng爸and牧ma給nag耗ing丟th冶eo第rga躍niz串a(chǎn)ti巖on璃par用tic見ipa導(dǎo)te狹in禍pla瘋nni細(xì)ng駱and牧me走asu車rin灶ga兔qu順ali倒ty縣imp盞rov鑼eme煩nt郵and捎pa紙tie談nt鞋saf全ety庭pr遍ogr釀am.QPS鐘.2鞭Th頓eo杠rga缸niz盯ati唐on進(jìn)des執(zhí)ign粘sn遞ew縫and委mo青dif股ied腳sy摘ste醫(yī)ms叛a(bǔ)nd虛pr鑰oce諷sse柜sa俗cco岸rdi暗ng魂to邊qua舞lit視yi辯mpr享ove桂men煉tp受rin李cip遵les錯.QPS巾.3訂Th允eo季rga慚niz預(yù)ati超on’的sl腰ead蠢ers秧id園ent夢ify顯ke屈ym熊eas畢ure蜘si貫nt吐he少org榜ani蠢zat熟ion筋’s康str秩uct笨ure秩s,狼pro掃ces螺ses筋,a胸nd左out浩com詢es備to冤be即use大di匆nt田he鑄org暈ani郊zat熱ion躲wid劇eq蒸ual系ity叨im聲pro批vem倦ent乞an仗dp曠ati戀ent列sa黎fet遷yp淹lan塔.QPS晴.4哈In靠div御idu砌als掘wi愈th盤app饒rop教ria凡te厘exp爐eri耀enc允e,暈kno撥wle勸dge歪,a溫nd法ski蹲lls存sy頃ste被mat舒ica脆l(xiāng)ly合ag賤gre查gat命ea法nd她ana鴿lyz聞ed蠻ata侄in旁th樸eo驅(qū)rga早niz得ati榜on.QPS憑.5短T鉗he滾org跪ani唇zat病ion雜us撓es地an方int退ern買al瞞pro味ces演st膏ov壞ali炊dat野ed掌ata疏.QPS單.6段The爸or明gan原iza探tio箱nu拴ses主a暖def毯ine賞dp巧roc同ess堪fo脂ri詳den麗tif憶yin幟ga待nd信man治agi帖ng絡(luò)sen農(nóng)tin壺el柄eve僑ntsQual澇ity碗Impr工ovem育ent穗and盾Pati甚ent彩Safe星ty(愁QPS)叔質(zhì)量改督進(jìn)與患者首安全QPS.維1醫(yī)羅院責(zé)任人愉和管理者議參與質(zhì)量爹改進(jìn)、患撥者安全項(xiàng)最目的計(jì)劃論與監(jiān)控QPS.深2醫(yī)之院按照質(zhì)茶量改進(jìn)原煌則重新設(shè)所計(jì)或修定橡各種體系蹲與流程QPS娛.3吐在完權(quán)善醫(yī)院蹈結(jié)構(gòu)、燙流程及牙結(jié)果中僚，領(lǐng)導(dǎo)修制定應(yīng)仰用于醫(yī)市院領(lǐng)域脅質(zhì)量改雷進(jìn)和患終者安全楚計(jì)劃的膛關(guān)鍵措梁施QPS.明4由建具有相應(yīng)慰經(jīng)驗(yàn)、知錘識及技能殖的人員系解統(tǒng)地收集流和分析醫(yī)剩院數(shù)據(jù)QPS吼.5榆醫(yī)院伏用內(nèi)部灰程序確鍛認(rèn)數(shù)據(jù)QPS謙.6矮醫(yī)院制項(xiàng)定程序樂，確定聾和管理此警哨事乏件Qual香ity位Impr溫ovem影ent免and望Pati長ent抗Safe山ty(千QPS)翅質(zhì)量改激進(jìn)與患者格安全QPS劉.7梅Dat滿aa嚴(yán)re奪ana傻lyz積ed爽whe認(rèn)nu雖nde存sir升abl些et型ren壞ds惡and中va昏ria枝tio鏈na遞re珍evi豬den如tf公rom濫th券ed璃ata猴.QPS.腰8Th庸eor襖gani違zati查onu果ses搏ade致fine舊dpr揀oces挪sfo籮rth袖eid振enti蛇fica堅(jiān)tion長and悼ana退lysi滿sof喜nea賊r-mi匆sse榜vent啊s.QPS掌.9堡Im寨pro猴vem隊(duì)ent擴(kuò)in臘qu歐ali處ty切and謀sa滴fet視yi吵sa煎chi商eve肢da南nd災(zāi)sus膛tai瓦ned竹.QPS.妹10I執(zhí)mpro腿veme奴nta壁nds紹afet惰yac以tivi慘ties羊are榨und睜erta侍ken序for收the綿prio煙rity淡are穗asi碎dent摧ifie社dby攜the激org爸aniz協(xié)atio披n’s柏lead密ers.QPS猜.11舍An社on崇goi什ng必pro注gra蝦mo磨fr變isk倒ma步nag司eme插nt車is錯use慘dt秒oi肺den波tif局ya伴nd銜to愚r(nóng)ed育uce隸un許ant宴ici鏈pat胸ed夢adv肝ers拌ee煤ven居ts蘆and召ot允her施sa勞fet面yr扔isk以st夸op辦ati集ent荒sa宣nd體sta蛋ff.Qua浩lit礦yI繭mpr撐ove泳men蔑ta穿nd汽Pat拜ien舌tS病afe滲ty甚(QP搜S)撫質(zhì)量改用進(jìn)與患氧者安全QPS洞.7臥數(shù)據(jù)顯亞示不良胸趨勢和譯變異時乎，分析腸數(shù)據(jù)QPS嫁.8朱對臨近肅差錯事兆件的確陣認(rèn)和分咽析，醫(yī)圍院按既夢定程序攤辦理QPS.脖9質(zhì)課量與安全三改進(jìn)到位信并維持QPS販.10早醫(yī)院拳領(lǐng)導(dǎo)確貧定的重哨點(diǎn)領(lǐng)域豆承擔(dān)了侍改進(jìn)與勻安全活愚動QPS.梅11持哀續(xù)的風(fēng)險嚷管理程序糟應(yīng)用于確杯認(rèn)和減少淡對患者及稈員工的意輪外有害事錄件與其他撓安全風(fēng)險Pre昨ven輪tio駕na雕nd疊Con溫tro托l(wèi)o陣fI挪nfe臣cti朋ons積(P濾CI)息感染域預(yù)防與類控制PCI挎.1核O抽ne以or瞇mor炊ei伐ndi雅vid心ual理so渣ver演see蕩al由li悼nfe甘cti綢on苗pre燭ven協(xié)tio川na洽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感經(jīng)染預(yù)防與精控制PCI.耗7炒The瀉orga啦niza觀tion肺ide零ntif介ies掀the匙proc售edur貞esa自ndp芹roce縫sses吵ass大ocia塘ted沒with縮慧the滴ris印kof公inf手ecti卻ona辨ndi傻mple妄ment飽sst鐵rate辯gies竄to看redu紡cei切nfec雅tion腳ris廊k.PCI勢.8廳T鏈he萌org趕ani各zat維ion暑pr祥ovi錢des露ba隸rri碌er逼pre姑cau膠tio昨ns津and蕉is決ola剖tio炊np文roc塊edu警res種th跌at正pro鬧tec員tp疼ati牛ent茄s,糠vis慶ito剝rs,混an而ds掘taf戰(zhàn)ff少rom面co蠻mmu問nic白abl刊ed黑ise嚼ase凝sa朽nd廈pro揀tec扁ts須imm覆uno龜sup喉pre稀sse陰dp喜ati必ent幟sf祝rom歷ac載qui被rin駛gi蘿nfe糾cti域ons修to惠wh節(jié)ich模th笛ey策are坑un稿iqu任ely宇pr便one儲.PCI積.9捉G攤lov另es,誰ma孫sks敢,e陸ye樣pro扎tec沈tio得n,晴oth特er綁pro葡tec板tiv亭ee味qui痕pme節(jié)nt,籍so臂ap,磚an邪dd結(jié)isi敏nfe晚cta盾nts卷ar跨ea永vai勢lab踐le慌and倆us棚ed焰cor扎rec駛tly旅wh背en泄req解uir徐ed.PCI.獸10T屠hei牲nfec鼻tion盛pre乳vent巨ion效and御cont鐘rol面proc賽ess摸isi忽nteg詢rate秀dwi穗tht盒heo爬rgan于izat莫ion’尾sov年eral醉lpr墓ogra后mfo液rqu嚴(yán)alit槍yim怨prov未emen期tan障dpa遵tien勉tsa負(fù)fety沖.PCI孫.11棍Th猾eo鑰rga燦niz膠ati闖on懲pro巨vid征es瞇edu突cat怖ion崖on桐in腸fec所tio佳np崖rev豪ent港ion絨an拼dc死ont茂rol選pr牢act勺ice億st喇os扒taf圍f,宿phy奏sic膨ian樸s,被pat注ien倆ts,逝fa躲mil送ies斃,a疾nd娘oth普er蛾car讀egi怎ver選sw鬼hen挖in跪dic狠ate牲db慚yt烘hei便ri耀nvo鐮lve倍men負(fù)ti云nc躺are百.Prev舊enti雜ona璃ndC蜓ontr悉olo袋fIn柿fect菌ions瞇(PC螺I)

感索染預(yù)防與俘控制PCI.構(gòu)7聯(lián)醫(yī)院確定紹應(yīng)對感染躲風(fēng)險的程乎序和過程王，并實(shí)施諷減少感染槐感染風(fēng)險撐的策略。PCI.引8債醫(yī)院提供剩防范屏障都和隔離程蹈序，保護(hù)驢患者、探卸視者及員認(rèn)工免得傳令染病，特墨別要保護(hù)味來自易感管人群的免姥疫抑制患救者。PCI.悠9提箏供手套、歸口具、眼瘋罩,及其少他防護(hù)設(shè)嗓備、肥皂貨和消液,遙在需要時箱能正確使澡用。PCI傲.10專感染蔬預(yù)防與曾控制整豈合于醫(yī)逆院總體朵質(zhì)量改針進(jìn)和患運(yùn)者安全章程序。PCI.齡11醫(yī)脅院對必須還參與治療防的員工、礙醫(yī)師、患丘者、家屬貨及其他護(hù)噸理人員提輛供感染預(yù)勺防與控制魄教育。Gov警ern痛anc瘋e,刻Lea舊der男shi黎p,續(xù)and憂Di顛rec脹tio考n(巖GLD偵)

政汗府、領(lǐng)任導(dǎo)和指揭南GLD.真1G雕over蟲nanc溉ere土spon要sibi面liti陵esa希nda控ccou湯ntab莖ilit既ies花are刑desc嫌ribe歉din幣byl釘aws,駝pol磨icie皇san的dpr洲oced造ures志,or底sim廳ilar篩doc料umen鑼tst芳hat丘guid使eho衰wth宇eya秒ret膛obe致car抵ried原out爽.GLD.訪2A涂sen跳ior呼mana仿ger陵ord素irec現(xiàn)tor槽isr咸espo快nsib騎lef憐oro萬pera至ting筋the椒org稍aniz灰atio肢nan步dco甲mply真ing僑with扎app究lica艷ble述laws肆and供reg汗ulat論ions晴.GLD.竟3T笨heo符rgan堤izat蛋ion’曠sle哪ader脂sar持eid幼enti獄fied剩and看are重col詞lect美ivel略yre永spon寧sibl意efo餃rde莫fini嶄ngt爸heo星rgan緩izat拒ion’刺smi認(rèn)ssio笨nan取dcr筍eati宗ngt確hep粉lans任and動pol嫁icie竄sne朽eded煙to怪fulf鞋ill生the差miss聲ion.GLD.某4M臂edic泉al,所nurs圣ing,完and權(quán)oth遭erl增eade省rso遣fcl螞inic艷als溉ervi壯ces抓plan津and目imp輪leme忌nta鞏nef貞fect鼻ive族orga但niza洪tion宜als雕truc我ture僚to忘supp做ort莊thei臺rre侵spon培sibi葬liti靜esa白nda喪utho高rity壯.GLD聽.5挑On魄eo技rm董ore耐qu瓶ali脈fie栽di肥ndi獵vid猛ual摟sp率rov店ide攻di憲rec路tio猶nf稀or召eac推hd純epa疊rtm藥ent戴or瓣se溜rvi酒ce棋in烤the基or款gan稅iza晚tio戰(zhàn)n.GLD用.6到Th跌eo請rga痰niz哄ati論on創(chuàng)est明abl雁ish摸es鑒af雜ram警ewo雷rk鍵for鏟et龍hic腰al驢man德age至men社tt香hat念en夫sur險es偽tha燭tp踩ati嶄ent薦ca林re屢is江pro娛vid絞ed像wit仙hin喝bu怒sin耕ess疊,f出ina兇nci新al,畝et線hic諸al,院an竟dl維ega谷ln貼orm項(xiàng)sa踐nd搖tha宗tp剖rot雨ect納sp憲ati找ent羞sa事nd疫the五ir藏rig押hts努.Gov蕉ern雹anc令e,號Lea臟der拌shi敏p,論and顏Di仍rec釘tio煤n(商GLD把)

政四府、領(lǐng)胡導(dǎo)和指奏南GLD奶.1識政府豎責(zé)任與汗職責(zé)表貫述為制吹度、政獵策和程警序，或殊明確如鐮何貫徹茄實(shí)施類醫(yī)似文件破。GLD.右2高越管或主管恐對醫(yī)院運(yùn)拳行負(fù)責(zé)，盾并遵守適達(dá)用法律和死法規(guī)。GLD花.3科醫(yī)院領(lǐng)導(dǎo)人確款定，并集咸體負(fù)責(zé)制勝定醫(yī)院使老命,創(chuàng)建鄰實(shí)現(xiàn)使命酸所需要的泰規(guī)劃和政悅策。GLD征.4醫(yī)療、護(hù)貿(mào)理及其他佳臨床服務(wù)巷的領(lǐng)導(dǎo)者廁計(jì)劃并執(zhí)扣行有效的傳組織結(jié)構(gòu)肚，支持其賢責(zé)任和權(quán)彼威。GLD.唐5一個或鞭多個有練資質(zhì)的甩人員對段醫(yī)院的咳每個科螺室或服賠務(wù)提供藝指導(dǎo)。GLD質(zhì).6保證為旋患者提館供的治億療符合菠商業(yè)、采金融、撿倫理、掘法律規(guī)脆范，并呈保護(hù)患引者和他槐們的權(quán)迫利。Faci割lity廢Man減agem禮ent崗and芒Safe天ty(餅FMS)絲式設(shè)施管警理和安全FMS.斷1T昌heo穩(wěn)rgan氣izat細(xì)ion佛comp鉗lies字wit廈hre裕leva攔ntl逮aws,揚(yáng)reg婦ulat旗ions廈,an場dfa歸cili語tyi測nspe患ctio賄nre莊quir秘emen熊ts.FMS.珠2T粒heo激rgan捕izat桶ion冷deve由lops幕and返mai箱ntai財(cái)nsa狗wri勞tten三pla橡n(s)睜des狂crib菜ing鎮(zhèn)the遠(yuǎn)proc丟esse至sto所man薯age悶risk塞sto翻pat默ient件s,f匙amil商ies,東vis衛(wèi)itor遺s,a舌nds抓taff學(xué).FMS.臭3O良neo踏rmo還req鐘uali毛fied價ind屈ivid蘭uals透ove貪rsee跡the懼pla掩nnin肚gan舍dim撈plem灑enta晚tion衡of等the畫prog路ram平tom笛a(bǔ)nag仁eth灶eri組sks姓int瓜hec穗are撫envi址ronm業(yè)ent.FMS呆.4褲Th滋eo煩rga租niz泛ati葉on秤pla系ns綢and毯im盯ple長men月ts壤ap茄rog肉ram劍to碎pr極ovi狡de皺as存afe叉an起ds親ecu臘re油phy輔sic聲al示env抓iro蕩nme鐵nt.FMS冶.5妖Th被eo唯rga爪niz熊ati址on頃has籠a次pla角nf鼠or虎the床in愿ven保tor這y,尺h(yuǎn)an撓dli奔ng,文st棒ora階ge,犁an診du艷se相of此haz留ard漁ous障ma乞ter兄ial斗sa沾nd猶the街co扒ntr置ol方and朝di左spo盛sal寫of信ha蓄zar岔dou型sm夸ate海ria袍ls蹈and搞wa會ste絕.FMS攏.6秘Th竄eo彈rga取niz襪ati想on過dev寧elo限ps橫and勢ma灑int螞ain億sa循ne彈mer車gen熔cy斑man暫age倒men極tp阿lan細(xì)an殃dp廳rog衰ram桂to旦re綁spo流nd貢to婚lik蒜ely枕co須mmu媽nit帳ye幅mer惠gen伏c(diǎn)ie靜s,慘epi膀dem壓ics絮,a撿nd鐮nat機(jī)ura易lo景ro壺the蒼rd拳isa兄ste紙rs.Faci礦lity全Man鼠agem芒ent批and宏Safe得ty(灶FMS)常設(shè)施管怪理和安全FMS.泡1醫(yī)鳥院遵守有稍關(guān)法律、脂法規(guī)和設(shè)救備檢查要皆求。FMS極.2器醫(yī)院罷編寫和僚維護(hù)了疏描寫管承理患者霉、家屬真、探訪鉆者和工疼作人員黎風(fēng)險過死程的書娃面方案低。FMS.閘3一水個或多個胃有資格的蒙人員監(jiān)督從管理治療戴環(huán)境風(fēng)險嚇程序的計(jì)蘇劃和實(shí)施夫。FMS犬.4寬醫(yī)院穩(wěn)計(jì)劃和飽實(shí)施了片提供安撿全可靠突的硬件較環(huán)境的瓜程序FMS.瀉5醫(yī)炸院有危險額物品的清博點(diǎn)、處理嚼、貯存、族使用及危相險品與廢敞物的控制胃和清理計(jì)秘劃。FMS.嗓6醫(yī)治院編寫和鳳維護(hù)應(yīng)對炭可能的社劫區(qū)緊急事咸件、流行兆病、自然損或其他災(zāi)吧害的緊急凈管理方案屆與程序Faci度lity閣Man貴agem悄ent捏and經(jīng)Safe微ty(桃FMS)培設(shè)施管顛理和安全FMS.葵7T質(zhì)heo堅(jiān)rgan們izat么ion看plan惰san諸dim譜plem閱ents冊ap原rogr猴amt繁oen舍sure翻tha幼tal舟loc貓cupa蜓nts能are龍safe炎fro斤mfi巧re,臺smok瀉e,o驗(yàn)rot明her解emer執(zhí)genc孩ies川int跳hef迅acil尋ity.FMS.組8T莖heo釋rgan舒izat澤ion境plan豆san踩dim煉plem每ents秩ap侮rogr蓄amf習(xí)ori腔nspe懂ctin肺g,t濤esti百ng,帳and距main吹tain體ing旦medi揮cal圈equi熱pmen褲tan付ddo議cume賴ntin詳gth悅ere撐sult于s.FMS齡.9斯Po化tab純le懇wat踏er耳and驅(qū)el野ect怕ric昏al財(cái)pow名er握are淘av贈ail化abl國e2裝4h主our篇sa脆da露y,疫sev讀en靜day訊sa電we劇ek,倉th雕rou佩gh將reg社ula累ro壓ra縮慧lte瞇rna朱te唱sou續(xù)rce城s,玻to卵mee桐te落sse斯nti皮al菌pat逢ien屈tc寬are陸ne暢eds英.FMS.姑10E級lect鑒rica文l,w馬ater著,wa活ste,凡ven像tila針tion樸,me敵dica脅lga絞s,a撤ndo過ther題key確sys刷tems屠are哪reg顫ular瞇lyi嘗nspe紫cted止,ma宅inta戒ined毅,an精d,w含hen撕appr躁opri登ate,文imp臟rove害d.FMS.績11T臥heo缸rgan湯izat遲ion窗educ惱ates蠻and屢tra樸ins拐all眉staf唐fme說mber芳sab類out材thei健rro慘les伙inp季rovi六ding務(wù)as沫afe增and揉effe額ctiv贊epa走tien營tca薦ref嗎acil濤ity.Fac康ili水ty做Man逮age淘men彈ta跑nd白Saf頂ety天(F墻MS)凳設(shè)施倍管理和浸安全FMS戰(zhàn).7警醫(yī)院譜制定和交實(shí)施了輝一個程浩序,確潔保所有握住戶是下遠(yuǎn)離設(shè)遼備意外貼發(fā)生的貝火災(zāi)、乏煙霧、熱或其他孝突發(fā)事沫件。FMS.乞8醫(yī)桿院制定和淺實(shí)施一個翅檢查、測慣試、維護(hù)求醫(yī)療設(shè)備炒的程序，倘并記錄結(jié)局果。通過常辯規(guī)或備唐用源，捕飲用水日和電力鑰一周7更天、一綁天24該小時可楚用，以消滿足基底本患者焦的治療酸需求。FMS相.10德定期吹檢查和綠維護(hù)電王氣、水做、廢棄淘物、通合風(fēng)、醫(yī)以用氣體錯和其它距關(guān)鍵系筒統(tǒng)，并異在適當(dāng)折的時候諸予以改買進(jìn)FMS.五11醫(yī)武院教育和趟培訓(xùn)全體詳員工在為券患者提供劍安全、有究效的治療惠設(shè)施時所稼應(yīng)扮演的錄角色。Sta將ff唇Qua森lif江ica倘tio綠ns兼and脈Ed慶uca坊tio羨n(宴SQE養(yǎng))

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