目的应用PDCA循环分析手卫生持续改进工作存在的主要问题,找出原因,落实措施,持续提高手卫生执行率和正确率。方法 2014年1月—6月以PDCA循环法的思路,全面加强培训,增强手卫生意识,加强监管,评价持续改进效果。比较PDCA循环运用前(2013年7月—12月)和运用后(2014年1月—6月)手卫生知识考核情况、手卫生设施增加情况、手卫生用品使用情况及手卫生执行情况。结果运用PDCA循环后,手卫生知识合格率由61.0%提高到88.3%,手卫生用品使用总量由1 817 046 m L增加到3 347 386 mL,手卫生执行率由43.03%提高至71.31%,手卫生执行正确率由62.68%提高至87.68%,差异均有统计学意义(P<0.05);不同手卫生指征的执行率在PDCA实施前后差异均有统计学意义(P<0.05),其中无菌操作前、接触体液后手卫生执行率增长较高(分别为34.56%、34.01%)。结论通过PDCA循环在手卫生工作中的应用,逐渐提高了手卫生的执行率和正确率。 Objective To analyze the main problems in the continuous improvement of hand hygiene by using PDCA cycle, find out the reasons and implement measures to continuously improve the implementation rate and correct rate of hand hygiene. Methods From January to June 2014, based on the PDCA cycle method, we comprehensively strengthened training, enhanced hand hygiene awareness, strengthened supervision and evaluated the effect of continuous improvement. Prior to the PDCA cycle (July-December 2013) and after use (January-June 2014), hand hygiene assessment, hand hygiene facilities, hand hygiene and hand hygiene performance were compared. Results After passing the PDCA cycle, the pass rate of hand hygiene was increased from 61.0% to 88.3%, the total amount of hand hygiene products increased from 1817 046 m L to 3 347 386 mL, the hand hygiene rate increased from 43.03% to 71.31% The correct rate of hand hygiene was increased from 62.68% to 87.68%, the difference was statistically significant (P <0.05). The implementation rates of different hand hygiene indications were significantly different before and after PDCA (P <0.05) Before aseptic operation, hand hygiene rates increased significantly following exposure to bodily fluids (34.56%, 34.01%, respectively). Conclusion The application of PDCA cycle in hand hygiene work gradually improves the implementation rate and accuracy of hand hygiene.