目的:探讨根本原因分析法(RCA)对提高消毒供应室管理质量和控制感染率的效果.方法:回顾性分析2014年1月～2015年12月我院消毒供应室已发生的不良事件,找出事件根本原因,改进管理措施,统计医院感染率;并于2016年1月～2017年2月实施改进后的管理措施,统计不良事件发生情况与医院感染发生率.结果:实施后管腔类器械清洗不合格发生率0.31％,无菌包标签日期错误发生率0.44％,无湿包发生,外标签与包内器械不相符发生率0.18％,与实施前相比明显下降且差异有统计学意义(P<0.05);实施后医院感染率为5.91％,低于实施前0.43％(P<0.05).结论:应用RCA改进消毒供应室管理措施可有效降低不良事件发生率,提高医院感染控制效果.%Objective: To explore the effect of root cause analysis method ( RCA) in improvement of the management quality of disinfection supply room and the control of infection rate.Methods:The adverse events occurred in the disinfection supply room of our hospital in the period from January 2014 to Decem-ber 2015 were analyzed retrospectively, so as to find out the root causes, improve the management measures, and conduct statistics on infection rate of the hospital; the improved management measures were implemented from January 2016 to February 2017, and an statistics were conducted to the occurrence of adverse events as well as the infection rate of the hospital.Results:After implementation of improved management measures , the nonconformity rate of metal piping instruments cleaning was 0.31％, the error rate of sterility packaging and labeling was 0.44％, there was no wet package, and the occurrence rate of inconsistency between outer labels and packed instruments was 0.18％, with a significant decrease than those before the implementation of improved management measures, and the different was statistical significance(P<0.05); after the implementation of improved management measures, the infection rate of the hospital was 5.91％, lower than 0.43％ before the implementation of improved management measures(P<0.05).Conclusion: Through im-provement of disinfection supply room management measures with RCA , it could effectively reduce the occurrence of adverse events and improve the infec-tion control effect of the hospital.
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