RCA2在一例软式内镜灭菌引起表皮破裂不良事件中的应用效果  

Application effect of RCA2 in a case of adverse event of epidermal rupture caused by soft endoscopy sterilization

作　　者：邹晓莲[1] 欣惠惠 刘云[1] 傅高虹 潘芳萍 王海云 ZOU Xiaolian;XIN Huihui;LIU Yun;FU Gaohong;PAN Fangping;WANG Haiyun(Jiangsu Huai'an Rehabilitation Hospital/Jinhu County People's Hospital,Huai'an 211600,China)

机构地区：[1]江苏省淮安市康复医院/金湖县人民医院,江苏淮安211600

出　　处：《临床医学研究与实践》2025年第9期171-174,共4页Clinical Research and Practice

摘　　要：目的通过对1例软式内镜灭菌后弯曲部表皮破裂事件的分析,探讨根本原因分析行动(RCA2)理念在医院消毒供应中心不良事件管理中的应用效果。方法针对1例软式内镜环氧乙烷灭菌后出现弯曲部表皮破裂事件,消毒供应中心联合相关科室、部门成立RCA2小组,调查事件过程,进行近端原因分析,找出根本原因。同时,对全院送至消毒供应中心处理所有软式内镜再生处理过程进行隐患排查,根据存在问题定制一系列改进措施(包括完善软式内镜处理流程、质量标准、建立档案,制作包内警示牌、插入部保护套、处理口诀、标准化测漏、规范培训的专业性和有效性等),并对改进效果进行近期及远期追踪评价。结果2020年(干预前),质量缺陷发生率为7.50%(15/200)、安全隐患发生率为6.00%(12/200)、器械维修总费用2.56万元;2021年(干预后),质量缺陷发生率为2.08%(5/240)、安全隐患发生率为3.33%(8/240)、器械维修总费用0.98万元。临床科室满意度提高,工作人员创新能力提升。结论将RCA2理念用于消毒供应中心不良事件管理中,有助于提高消毒供应中心不良事件处置能力,提高工作质量,保障了器械在再生处理过程中的安全性。Objective To explore the application effect of root cause analysis and actions(RCA2)concept in the management of adverse events in hospital disinfection sterile supply center by analyzing a case of epidermal rupture in the curved part of flexible endoscope after sterilization.Methods In view of one case of epidermal rupture of curved part after ethylene oxide sterilization of soft endoscope,the disinfection and supply center,together with relevant departments and departments established RCA2 team to investigate the process of the incident,analyze the proximal causes and find out the root causes.At the same time,the hidden dangers of all soft endoscope regeneration processes in the disinfection supply center of the whole hospital were investigated,and a series of improvement measures were customized according to the existing problems(including improving the soft endoscope processing flow,quality standards,establishing archives,making warning signs in the package,inserting protective sleeves,processing tips,standardized leak detection,and standardizing the professionalism and effectiveness of training).The effectiveness of the improvements was evaluated both in the short and long term.Results In 2020(before intervention),the incidence of quality defects was 7.50%(15/200),the incidence of safety hazards was 6.00%(12/200),and the total cost of equipment maintenance was 2.56 million yuan;in 2021(after intervention),the incidence of quality defects was 2.08%(5/240),the incidence of safety hazards was 3.33%(8/240),and the total cost of equipment maintenance was 0.98 million yuan.The satisfaction of clinical departments was improved,and the innovation ability of staff was improved.Conclusion The RCA2 concept is used in the management of adverse events in the disinfection supply center,it is helpful to improve the ability of the disinfection supply center to deal with adverse events,improve the quality of work,and ensure the safety of the equipment in the regeneration process.

关 键 词：消毒供应中心 软式内镜 根本原因分析行动 灭菌 

分 类 号：R197.32[医药卫生—卫生事业管理]