目的了解某基层医疗机构口腔诊疗器械灭菌失败的原因,探讨解决措施。方法通过现场观察、个人访谈等方法开展调查。结果该基层医疗机构使用小型压力蒸汽灭菌器进行复用医疗器械灭菌,本次灭菌失败的直接原因为灭菌物品装载过量。该基层医疗机构未开展消毒灭菌操作人员岗前及岗中培训、未开展有效的内部自查工作是导致灭菌失败事件发生且未能主动发现的重要原因。结论应采取多种措施,督促基层医疗机构提高消毒灭菌自身管理水平,包括:加强培训指导提高基层医疗机构的消毒灭菌管理工作主体责任意识;建设多元化培训平台,为基层医疗机构消毒灭菌工作人员的专业培训提供便利条件;定期开展外部监督,监督医疗机构落实内部自查制度。 Objective To understand the reasons for the failure of oral cavity medical equipment sterilization in a grassroots medical institutions and to discuss the solutions. Methods Through field observation, personal interviews and other methods to carry out investigations. Results The primary medical institutions used small pressure steam sterilizer to re-use medical equipment to sterilize. The direct reason for this sterilization failure is overdosage of sterilized articles. The primary medical institutions did not carry out pre-job and post-training of disinfection and sterilization operators, the failure to carry out effective internal self-examination is the leading cause of sterilization failure and failed to take the initiative to discover the important reasons. Conclusion Various measures should be taken to urge primary-level medical institutions to improve their self-management level of sterilization and disinfection, including: strengthening training and guidance to raise awareness of primary responsibility for disinfection and sterilization management in grassroots medical institutions; building a diversified training platform for disinfection and disinfection of primary medical institutions Professional training of bacteria staff to facilitate the conditions; regular external supervision, supervision of medical institutions to implement internal self-inspection system.