降低供應室寄消品滅菌前準備不完整率之方案

滅菌品質是感染管制及病人安全之重要指標。本專案目的旨在降低供應室寄消品滅菌前準備之不完整率。專案期間經由查檢寄消包545包，統計其滅菌前準備的完整性，調查結果發現供應室寄消品滅菌前準備不完整率90.5%，不完整項目主要有：未標示寄消包名稱、侵入性物品未置放包內化學指示劑、未正確標示有效日期，經分析確認主要問題的原因為無標準作業流程、教育訓練不足及缺乏監控機制等。經由制訂寄消品滅菌前準備標準作業流程、辦理相關教育課程、設計寄消單位之寄消品滅菌前準備自我查檢表及制訂供應室之監督機制與審核單等方法，致供應室寄消品滅菌前準備不完整率由90.5%降低至8.5%，進而提昇寄消品之滅菌品質，保障病人安全。

關鍵字

供應室；醫療器材；清潔；打包；滅菌

並列摘要

Proper sterilization of equipment is critical issue for infection control and patient safety. Sterilization is done in the central supply room (CSR), but the packages of equipment to be sterilized are often made up in non-CSR units elsewhere in the hospital. From August 15 to 30, 2007, 545 such non-CSR packages were evaluated, of which 493 90.5%) were improperly prepared. The commonest errors were poor labeling, failure to include a chemical indicator, and lack of an expiration date. Systemic reasons for these errors included the lack of a standard operating procedure for packaging by non-CSR units, inadequate knowledge and training for the staff, and the lack of a monitoring system. These issues were addressed by establishing standard guidelines for use by every unit, providing training for staff who reprocess and prepare medical equipment for sterilization, distributing a check list for non-CSR units to make sure the equipment was properly packed according to the guidelines, and establishing a CSR monitoring system. After implementing these measures, the rate of non-compliance by non-CSR units fell to 8.5%

並列關鍵字

central supply room (CSR) ； medical equipment ； cleaning ； packaging ； sterilization

國際替代計量

降低供應室寄消品滅菌前準備不完整率之方案

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