提升鼻咽內視鏡再處理作業正確率

Improving the Accuracy Rate of Nasopharyngoscope Reprocessing

目的：首要建立單位鼻咽內視鏡再處理標準作業流程。其次，依據文獻建議，設定鼻咽內視鏡再處理作業正確率目標為95％。方法：制定鼻咽內視鏡檢查管理程序書並明定步驟權責人員，確認內容並繪製流程圖，提供參考。其次，安排教育課程，使同仁獲得相關知識，並利用晨會及科會向醫療團隊說明作業標準及重要性。過程持續評值改善措施。結果：本專案建立簡潔清楚的鼻咽內視鏡再處理作業流程，並將其寫入單位管理程序書。執行5個月後，單位再處理作業正確率可達95％目標值。結論：本專案改變醫療人員作業習慣，建立符合感染管制規範的鼻咽內視鏡再處理作業標準。建議日後拍攝操作步驟影片、將在職教育及操作課程納入新進耳鼻喉科醫師與護理師訓練計畫、定期稽核鼻咽內視鏡再處理作業正確率，使醫護人員具備正確的知識及技能，維護病人安全。（澄清醫護管理雜誌2020；16（3）：55-64）

Purposes: The primary objective of this study was to establish a standard operating procedure for nasopharyngoscope reprocessing at our hospital, while the secondary objective was to achieve an accuracy rate of 95% for this procedure based on recommendations in the literature. Methods: We formulated a management procedure for nasopharyngoscope reprocessing and defined the role and responsibility of the personnel involved at each step. The procedure was then reviewed and simplified, and a flowchart was prepared for reference. Next, training courses were held to educate the medical staff on the newly formulated standard operating procedure. In addition, the procedure and its importance were reiterated to them at daily and departmental meetings. Moreover, continuous evaluation and improvement measures during the process. Results: In this project, a concise and clear standard operating procedure for nasopharyngoscope reprocessing was established and incorporated into the hospital's management procedure. After implementation for 5 months, the accuracy rate of the reprocessing procedure in the hospital had reached the target value of 95%. Conclusions: In this project, the operation habits of medical personnel involved in nasopharyngoscope reprocessing were improved by establishing a standard operating procedure in line with the infection control regulations. It is recommended to produce a video of the operation steps, integrate the on-the-job education and operation courses into the training program for new ENT doctors and nurses, and regularly audit the accuracy rate of the nasopharyngoscope reprocessing, so as to ensure that the medical staff have the required knowledge and skills to guarantee patient safety. (Cheng Ching Medical Journal 2020; 16(3): 55-64)