消毒供应中心基于失效模式与效应分析法的医院感染风险管理实践  

Risk management of healthcare-associated infection in central sterile supply department based on failure mode and effect analysis

作　　者：赵霞[1] 王力红[1] 赵昕[2] 陈丽鸥[3] 赵会杰[1] 张京利[1] 马文晖[1] 韩叙[1] ZHAO Xia;WANG Li-hong;ZHAO Xin;CHEN Li-ou;ZHAO Hui-jie;ZHANG Jing-li;MA Wen-hui;HAN Xu(Xuanwu Hospital,Capital Medical University,Beijing 100053,China)

机构地区：[1]首都医科大学宣武医院医院感染管理处,北京100053 [2]首都医科大学宣武医院医院消毒供应中心,北京100053 [3]首都医科大学宣武医院医院护理部,北京100053

出　　处：《中华医院感染学杂志》2020年第6期945-950,共6页Chinese Journal of Nosocomiology

基　　金：北京市属医院科研培育计划基金资助项目(PG2019018)。

摘　　要：目的建立消毒供应中心(Central sterile supply department,CSSD)医院感染风险监测与管理机制,优化医院感染管理策略,将医院感染预防与控制的关口前移。方法基于失效模式与效应分析法(Failure mode and effect analysis,FMEA),对首都医科大学宣武医院CSSD医院感染风险进行识别、定量分析及评价,查找需采取干预措施进行控制的重点风险,制定改进措施进行风险控制,并对控制效果进行评价,建立消毒供应中心风险监测和管理机制。结果 CSSD医院感染风险管理体系包括建筑布局不合理、人员管理不符合要求、操作流程不规范、设备运行失效及清洗消毒灭菌效果监测不合格等五大方面26个风险点;其中需采取措施进行控制的风险点7个。经过实施针对性改进措施,风险控制效果良好。结论基于FMEA对消毒供应中心进行定量风险评估,建立医院感染风险管理机制,可及时发现CSSD潜在感染风险,有效去除重大医院感染风险。OBJECTIVE To establish the healthcare-associated infection(HAI) risk management system so as to optimize the management strategy of HAI and move forward the key of prevention and control of HAI. METHODS The risks of HAI in CSSD quantitatively were identified through the failure mode and effect analysis(FMEA) to find the key risks that needed to be controlled. The special interventions were implemented and the effect was evaluated to establish the HAI risk monitoring and management mechanism. RESULTS The risk management system for HAI in CSSD included 26 risk points in five aspects: unreasonable building layout, unqualified management of personnel, nonstandard operation process, ineffective operation of equipment and failure of cleaning, disinfection and sterilization. There were 7 key risks that needed to be controlled. The control of the risks achieve favorable effect after the targeted interventions were taken. CONCLUSION The quantitative risk assessment based on FMEA and the establishment of HAI risk management system in CSSD may facilitate the timely discovery of potential risk of HAI and effectively remove the key risks of HAI.

关 键 词：消毒供应中心 医院感染 风险评估 失效模式与效应分析 

分 类 号：R197.32[医药卫生—卫生事业管理]