南部醫學中心逆滲透系統水質異常分析與改進措施

Analysis and Reduction of bacterial Contamination in a Central Reverse Osmosis Water System in a Medical Center in Southern Taiwan

逆滲透（Reverse osmosis，RO）系統對醫療機構的用水是非常重要的環節，尤其是在滅菌品供應中心、血液透析室與手術室方面。RO水質穩定性直接影響醫療操作的安全性與病人健康。2024年11月某醫療機構滅菌品供應中心的清洗消毒烘乾機，及中央RO系統的RO水出現總菌落數超標。進一步發現中央RO系統餘氯濃度不足的異常現象，透過數據分析探討異常原因，提出改進措施。本研究顯示，感染管制團隊透過例行監測及跨部門協調，得以及早發現中央RO系統水質異常並調整管理策略，提供醫院規劃醫療用水品質監測機制之參考。

In healthcare establishments, reverse osmosis (RO) systems are essential for ensuring patient safety, particularly in sterilization supply departments, hemodialysis units, and operating rooms. In November 2024, bacterial contamination was detected in the RO water used for cleaning and disinfection processes in the sterilization supply department of an institution. Investigations traced the source of contamination directly to the central RO water supply. Comprehensive data analysis enabled us to identify the underlying causes of the incident, and improvement interventions were subsequently reviewed and implemented. This incident provides insights and offers practical recommendations for enhancing water quality management in healthcare settings.