手術器械不正確使用改善專案

Project to Develop a Timesaving Technique for Preparing Outgoing Fresh Froze

『工欲善其事，必先利其器。』手術器械是手術執行重要的輔助工具。醫護人員能正確使用及供應室人員正確清洗保養，才能及時發揮最大功能。手術室工作步調快，手術進行時，若對器械操作訓練不足、組裝錯誤、貪圖方便未使用正確器械、欠缺保養等都會影響手術進行。本單位於2008年2月1日至2月29日，以查檢表實際調查手術器械因人為因素或保養疏失致損壞的情形，並向醫工查詢手術室器械送修資料，結果當月器械使用272人次，醫師反應使用不良次數38次，故障送修42件，損壞率為30%，分析原因包括人員使用習慣不佳、缺乏正確清洗觀念、無相關標準作業流程且無特定器械保養計劃、新進人員比例多、消毒時未正確封包，皆為器械損壞原因。因此針對上述問題點擬定改善方案。包含人員專業訓練與評值、技術操作教學光碟製作、制定標準工作規範等，經對策實施後再次以相同查檢表查檢，損壞率降為14%。藉此專案，除增加醫護人員對器械正確之使用，亦減少送修次數，使手術器械達到良好的使用效能。

The surgical instruments used during a surgical procedure must be properly cared for, and in prime condition in order to contribute to the success of the operation. After the maintenance and cleaning of the instruments is done by the CSR (Central Supply Room), personnel must have a thorough understanding of their status and condition for proper use. The rate at which instruments in the operating room are needed can be rapid, and if the instrument is assembled incorrectly, or if some necessary maintenance sequences have been deleted for the sake of convenience, it may be difficult for the surgery to proceed. From February 1 to February 29, 2008 a thorough investigation was carried out to survey the effect of the human factor on surgical instruments. A survey was used to assess the maintenance mistakes that were made, and any effect this had on the intended surgery. We also consulted with the instrument engineering room to understand the records which held information about the number of times the equipment was repaired and serviced. The result is as follows: during the same month, an instrument was used by 272 people, the number of times that the instrument was reported as malfunctioning by a doctor was 38 times, and the number of breakdowns that occurred which sent the instrument to be repaired was 42. The non-utilization ratio was 30%. The reasons for the instrument damage, as provided by the survey, were that the wrong personnel used the instrument, the instrument was not properly sterilized, the instrument was not properly incorporated into the standard work flow, there was no specific instrument maintenance plan, there was a large number of new, untrained personnel who used the instrument, or the instrument was incorrectly packed after disinfection. In order to draw up an improved plan, a training and evaluation program was implemented, instructional CDs for correct instrument operation were provided, and regular working standards were created. After the plan was implemented, an identical investigation was executed using the same survey. The non-correct utilization ratio was reduced to 14%. This project/plan successfully increased the correct use of instruments for members of the surgical teams. Also, the equipment requiring repair greatly decreased, which enabled the surgical instruments to be more efficiently utilized.