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目的:采用消毒供应中心(CSSD)信息追溯系统分析不良事件的发生原因,加强各环节的质量控制和管理,保障CSSD无菌物品的质量。方法:依据信息追溯系统全流程跟踪的信息采集数据,查找不良事件发生的环节以及责任人,由信息数据可以分析是系统还是客观原因并进行整改。结果:通过信息追溯系统详细的数据记录,回顾查找不良事件的当事人,查找事件发生痕迹,由此可以科学的分析事件发生的原因,提出正确的整改方向。结论:不断完善CSSD信息追溯系统建设,完善每一个流程中的数据采集,可以给CSSD各类不良事件提供事实数据进行分析,从而使CSSD质量得以持续改进和提高。
OBJECTIVE: To analyze the causes of adverse events using CSSD retrospective system to enhance the quality control and management of all aspects and ensure the quality of CSSD sterile products. Methods: Based on the information traced by the whole process of information traceability system, the data collected were searched to find out the links of the occurrence of adverse events and the responsible persons. Information data could be used to analyze the system or objective reasons and rectify them. Results: Through the detailed data records of the information traceability system, we can retrospectively find out the parties involved in the adverse events and find the traces of the events so that we can analyze the causes of the events scientifically and propose the correct direction of rectification. Conclusion: The continuous improvement of the CSSD information traceability system and improvement of data collection in each process can provide factual data for all kinds of adverse events of CSSD for analysis, so that CSSD quality can be continuously improved and improved.