器械滅菌作業在手術室扮演重要角色，一旦滅菌不完全將導致院內感染，影響病人安全及醫院聲譽。本專案是因發生手術器械包盤內試紙變色不完全之異常事件，經實地觀察人員執行器械滅菌作業流程，顯示缺乏標準器械滅菌作業監測制度、設備不完善及人員對器械滅菌作業認知答對率45.89%。本專案目的為提升器械滅菌作業完整性達100%，改善措施包括設立器械滅菌設備、進行教育訓練、制定標準器械滅菌流程及自主性查核。實施改善後顯示：1.人員對器械滅菌作業認知答對率提升至93.57﹪；2.自主性查核人員執行器械滅菌正確率97.08%；3.抽真空及生物測試作業並記錄完整率100﹪。結果證明器械滅菌作業完整性之改善，能確保手術病人安全及提升照護品質。

Instrument sterilization plays an important role in the operating room. Incomplete sterilization may cause nosocomial infection, and may sequentially influence the safety of patients and the hospital prestige. This project was originated because of an abnormal event of the indicator paper whose color was changed incompletely in surgery instruments. After the project members’ observation on the implementation of the sterilization protocol in the field, it indicates the lack of a standard operating procedure, shortage of the equipment, and poor knowledge of sterilization among the staff. Only 45.89% of the staff could answer the questions related to instrument sterilization correctly. The purpose of this project is to raise the rate of completion of the instrument sterilization to 100%. The project also included establishment of the sterilization equipment, implementation of the education and training programs, formulation of a standard procedure for sterilization work, and the independence of the checkup. The results of the project showed that: 1. the correct rate of the staff’s cognition to sterilization work reached 93.57%; 2.the correct rate of the independence of the checkup in sterilization work was 97.08%; and 3. the rate of pulling out vacuum, carrying out biological tests, and recording the procedure integrally was 100%. The results showed that this project of improving the instrument sterilization can increase the safety of patients and caring quality in operating room.