提昇臨床單位醫材盤包滅菌前準備之完整率

Raising the Completion Rate of Preparation for Medical Equipment Package Sterilization in Clinical Units

本專案目的在提昇臨床單位醫材盤包滅菌前準備之完整率，以落實衛生署病人安全目標之一的感染控制。改善前發現臨床單位為節省成本，醫材盤包滅菌前之準備方式皆不一致，如重複使用包布、未放置整條包內指示劑、醫材未洗淨及乾燥等。現況分析發現，其導因為缺乏滅菌之相關知識、標準作業流程、查核機制及相關設備，故運用決策矩陣分析方法擬定相關解決辦法，分別為制定盤包滅菌前準備作業之標準流程以提供人員遵守、舉辦在職教育訓練課程充實人員滅菌知識、制定查核機制引發人員改善動機及提供相關設備等措施。經專案實施後，其滅菌前準備之完整率由67%提昇至92.4%，進而提昇滅菌品質，落實病人安全控制。

Infection control policy of the Department of Health is implemented to ensure patients’safety. Therefore, the aim of this project was to raise the completion rate of preparation for medical　equipment package sterilization in clinical units. Due to reasons of cost saving, the clinical units adopted different methods of preparation for medical equipment package sterilization, such as reusing of wrapping cloth, usage without integrated package indicator, and insuffi cient cleaning or drying of the medical equipments. According to our observation and analysis, these situations were caused by a lack of knowledge in the areas of sterilization, standard operation procedure, auditing system and related equipments. Therefore, the decision matrix analysis was applied to this project to find multiple solutions, including revising standard operation procedure, promoting education programs, setting up an auditing system, and providing supplemental equipments. The completion rate has been raised from 67% to 92.4% after these solutions were implemented. The quality of sterilization and control of patients’ safety are secured.