提升手術室護理人員操作單門式高壓蒸氣滅菌鍋正確率之專案

A Project to Improve the Validity Rate for Nursing Staff Operating Single Door Autoclave Sterilizers

本專案在改善手術室護理人員操作單門式高壓蒸氣滅菌鍋正確率偏低，經現況調查發現，護理人員對滅菌鍋認知正確率為85%，另實務操作查檢正確率僅80%。其缺失分為兩方面：1.不安全行為：未遵循標準作業規範；缺乏操作相關知識；未建立稽核制度；2.不安全環境：鍋體傳送蒸氣之管路裸露及缺乏操作標示。經以下方案改善：舉辦在職教育、制定操作步驟流程圖、製作故障排除標準流程標示、鍋體裸露管路保溫防火阻隔工程施工、進行鍋體定期稽核。經介入方案後認知85%提升至100%，另操作正確率則由80%提升至100%，確保手術室安全工作環境建立一個零職災醫療環境。

This project was designed to improve the low validity rate for nurses responsible to operate single door autoclave sterilizers in the operating room. By investigating the current status, we found that the nursing staff validity rate of cognition on the autoclave sterilizer was 85%, and the practice operating check validity rate was only 80%. Such was due to a lack of in-service education. Problems with operation included: 1. Unsafe behaviors - not following standard procedure, lacking relevant operating knowledge and absence of a check form; 2. Unsafe environment-the conveying steam piping was typically not covered and lacked operation marks. Recommended improvement measures included: 1. holding in-service education; 2. generating an operation procedure flow chart; 3. implementing obstacle eliminating procedures; 4. covering piping to prevent fire and burns; 5. performing regular checks to ensure all procedures are followed. Following intervention, nursing staff cognition rose from 85% to 100%, while the operation validity rate rose from 80% to 100%. These changes ensure a safer operating room environment, and helps facilities move toward a zero accident rate in the healthcare environment.