某區域醫院運用根本原因分析改善胃鏡感染事件

Use Root Cause Analysis to Improve the Gastroscope Infection Events in a Regional Hospital

10.29681/PCJHM.201212.0003

曾貴英(Kuei-Ying Tseng)；賴素雲(Su-Yun Lai)；陳億玲(Yi-Ling Chen)；潘秋花(Chiu-Hua Pan)；高靜怡(Ching-I Kao)

根本原因分析 ； 胃鏡感染 ； 細菌培養 ； Root cause analysis ； endoscopy infection ； bacterial cultures

寶建醫護與管理雜誌

10卷2期（2012 / 12 / 01）

14 - 23

繁體中文

目的：運用根本原因分析胃鏡感染事件，透過工具找到原因進行改善，防止類似事件再發生。方法：以回溯性、訪談的方式，將整個事件過程口述並紀錄，清楚還原整個內視鏡採檢，培養報告呈陽性之過程，分析其根本原因有：1.內視鏡作業常規未明訂異常鏡檢之後續追蹤機制、2.洗滌機清潔未納入內視鏡作業常規、3.未明訂櫥櫃清潔作業，未有查核機制、4.空氣槍需打水至完全沒有水氣之狀況，未明訂於作業規範。擬訂改善方案：1.內視鏡作業常規明訂異常追蹤機制、2.洗滌機、櫥櫃清潔納入內視鏡作業常規、3.空氣排水標準納入內視鏡清潔消毒作業規範。結果：定期追蹤查檢胃鏡室洗滌機、櫥櫃清潔，檢測細菌培養為陰性，重新修訂「內視鏡消毒作業規範」、「胃鏡室工作職責及流程」。

Objective: Apply root-cause analysis to the gastro scope infection event, for continuous imporvements and to prevent from happening in future. Improvement plan development: Endoscopic operating practices, express abnormal tracking mechanism included in the endoscopic operating practices. Washing machine, cupboard clean, air drainage standards into endoscopic cleaning and disinfection operations specifications. Results: Regular follow-up with a search the gastro scope room washing machine, cupboard clean, detection of bacterial cultures were negative, revised endoscope disinfection job specification, the gastro scope room duties and processes.