CAJ | 학술논문

随着医学科技的进步，医疗护理服务技术的复杂性明显提高，不良事件时有发生，严重威胁病人安全。捕获有效的不良事件信息是降低其发生率最有效的措施，无责罚不良事件上报系统，意在建立一个无威胁性的环境和无惩罚性的安全文化氛围，能使员工消除顾虑，提高上报率。基于此系统和氛围，消毒供应室制订、完善或优化了相关的制度和操作流程，改进、落实管理监控措施，对上报的不良事件进行持续质量改进，从而减低了严重事故的发生，保证了各环节的工作质量，最终保证灭菌质量，保障病人安全。
수착의학과기적진보，의료호리복무기술적복잡성명현제고，불량사건시유발생，엄중위협병인안전。포획유효적불량사건신식시강저기발생솔최유효적조시，무책벌불량사건상보계통，의재건립일개무위협성적배경화무징벌성적안전문화분위，능사원공소제고필，제고상보솔。기우차계통화분위，소독공응실제정、완선혹우화료상관적제도화조작류정，개진、락실관리감공조시，대상보적불량사건진행지속질량개진，종이감저료엄중사고적발생，보증료각배절적공작질량，최종보증멸균질량，보장병인안전。
With the development of medical science and technology, medical care service technology became more and more complex and adverse events occurred occasionally which threat patients' safety. The capture of effective information of adverse events is the most effective measure to reduce the occurrence rate of adverse events. The aim of adverse events reporting without punishment system is to create an environment without threatens and a safety culture atmosphere without punishment so as to help staffs eliminate their worries and improve the reporting rate. To build this system and create the atmosphere, the related regulation and operation process were developed, improved or optimized by staffs from Disinfection and Supply Room. Moreover, the management and supervision measures were also improved and implemented. As to the adverse events reported through this system, we made continuous quality improvement to reduce the occurrence rate of severe accidents and guarantee the quality of every link of the working process. As a result, the sterilization quality and patients safety were ensured.