目的：提升全院感控理念，强化医院感染管理，从手卫生做起，提高医护人员洗手的依从性，降低医院感染，保证医患安全。方法：暗访118名医护及医技工勤人员接触患者前后、进行无菌操作前后、接触患者周围环境及体液后是否洗手，洗手是否规范，时间是否达到15秒。掌握医务人员手卫生依从性执行情况，加强全院医务人员手卫生意识，督促医务人员养成良好的洗手习惯。结果：通过暗访，手卫生合格率医生为39.58%，护士为44.62%；医技工勤为40.00%，未按手卫生规范洗手是不合格的主要原因。结论：手卫生是一种最基本、最简便、最易行的有效预防病原微生物传播的手段，是降低医院感染最重要的措施，创造重视手卫生氛围，可以有效地提高医护人员对手卫生的重视程度。%To enhance awareness of infection control, promote management of infection, improve the compliance of hand hygiene of doctor and nurse, so as to reduce the infection and ensure safety of doctor and pa-tients in the hospital. Methods: Undercover inquires were made among totally 118 health care provider, medical technicians and logistics to investigate if they washed hands before and after contacting patients and aseptic proce-dures, after touching surroundings and body fluids of patients. Meanwhile, if hand washing measured up for 15 sec-onds had also been researched. Execution of hand hygiene in the hospital was better understood to enhance the awareness of hand hygiene and encourage the health care workers to form good habit of washing hand. Results: Qualified rates of hand hygiene were concluded as follows: 39.58% in doctors, 44.62% in nurses and 40.00% in medical technicians and logistics. Washing hand without hand hygiene standard was the primary cause of disqualifi-cation. Conclusion: Hand hygiene, which is of highly basis, convenience and feasibility, can prevent the transmis-sion of pathogenic microorganism effectively and reduce the infection in the hospital. It's effective to create atmo-sphere of attaching importance to hand hygiene to raise awareness of it.
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