根本原因分析及追踪法在消毒供应中心的应用效果  

Application effect of root cause analysis and tracing method in disinfection supply center

作　　者：田岚[1] 张丽洁 白钰 TIAN Lan;ZHANG Li-jie;BAI Yu(Disinfection Supply Unit,Beijing Stomatological Hospital,Capital Medical University,100010,China)

机构地区：[1]首都医科大学附属北京口腔医院消毒供应中心,100010

出　　处：《传染病信息》2020年第2期186-189,共4页Infectious Disease Information

基　　金：北京市科技计划项目(D141100000315001)。

摘　　要：目的探讨根本原因分析法联合追踪法对消毒供应中心管理质量及控制医院感染的效果。方法抽检2018年10月8日—2019年1月20日我院消毒供应中心灭菌器械500件,统计不良事件发生情况及同期医院感染发生率。用根本原因法分析并找出不良事件发生的原因,落实质量管理,用追踪法追踪改进措施后的消毒灭菌质量情况。再于2019年1月21日—7月30日间抽检灭菌器械500件,统计不良事件发生情况及同时期医院感染发生率。比较分析根本原因分析法联合追踪法管理法(联合管理法)实施前后不良事件发生率及医院感染率。结果联合管理法实施后无菌包标签日期错误发生率为0.20%,器械清洗不合格发生率为0.40%,外标签与包内器械不相符发生率为0.20%,与联合管理法实施前相比明显下降,且差异均有统计学意义(P均<0.05)。联合管理法实施后医院感染率为1.20%,低于实施前的6.80%(P<0.05)。结论通过运用联合管理法改进消毒供应中心管理措施,可有效降低不良事件发生率,提高医院感染控制效果。Objective To investigate the effect of root cause analysis and tracing method on the quality of disinfection supply room management and control of nosocomial infection.Methods From October 8,2018 to January 20,2019,500 sterilization devices were randomly inspected in the disinfection supply center of our hospital to calculate the incidence of adverse events and nosocomial infection rate.Root cause analysis was used to analyze and find out the root cause of adverse events and implement quality management.Tracing method was used to track the quality after improvement measures were implemented.From January 21 to July 30 in 2019,another 500 sterilization devices were selected for sample inspection again,and the incidence of adverse events and nosocomial infection rate were calculated.The incidence of adverse events and nosocomial infection rate were compared before and after the implementation of root cause analysis combined tracing method(combined management method).Results After implementation of combined management method,the error rate of sterile package’s labeling date was 0.20%,the nonconformity rate of device cleaning was 0.40%and the inconsistency rate between outer labels and packed instruments was 0.20%.These incidences were obviously decreased compared with those before the implementation of combined management method,and the difference was statistically significant(P<0.05).After the implementation of combined management method,the nosocomial infection rate was 1.20%,lower than 6.80%before the implementation(P<0.05).Conclusions Through improvement of disinfection supply room management measures with combined management method,it can effectively reduce the incidence of adverse events and improve the effect of controlling nosocomial infection.

关 键 词：根本原因分析法 追踪法 消毒供应室 管理质量 

分 类 号：R47[医药卫生—护理学]