血液透析水質的品質管理對透析單位而言，攸關病人生命安全，管理監測不當可 能導致病人引發感染、敗血症甚至死亡。本單位於 2012 年第一季透析水質細菌培養 菌落數≧50 cfu/mL 異常率為 12.5％，第二季更攀升至 19.0％，調查原因為：同仁 未落實採檢技術且對透析水質品管知識不清楚、未修訂採樣標準作業以及缺乏相關教 育訓練、未建立稽核制度及異常追蹤管理。本專案經過臨床調查、現況分析及文獻查 證後，擬定措施：修訂透析水質採檢技術標準作業及制定透析水質品質管理記錄與稽 核表，舉辦教育訓練並建立稽核制度。對策實施後水質檢測異常率由 19.0％降至 0.9 ％，達到目標值。本專案提升單位同仁對血液透析治療與透析用水的品質與安全，確 實建立一個安心的醫療環境。

For dialysis units, the management of hemodialysis water quality is a crucial issue as it relates to patients’ lives and safety; poor management and monitoring may result in patient infections, septicemia, and/or death. Our dialysis unit underwent a dialysis water quality assessment in the first quarter of 2012 and determined that the bacterial colony count in the collected water samples (≥50 cfu/mL) exhibited an abnormal rate of 12.5%. In the second quarter of the same year, the assessment was conducted again and yielded a further increased abnormal rate of 19.0%. The causes of such high abnormal rates were examined, and the following results were obtained: The department staff did not follow the sampling and inspection procedures and possessed inadequate knowledge about dialysis water quality control; failed to revise the standard sampling procedure and lacked related education and training; lacked review or management systems for tracking abnormal cases. By performing a clinical investigation, current situation analysis, and literature review, this study revised the standard operating procedure for dialysis water sampling and inspection, created a form for recording and reviewing dialysis water quality management, held education and training sessions, and established a review system for staff performance. After implementing the aforementioned measures, this study decreased the colony count abnormal rate from 19.0% to 0.9%, meeting the target value. This study successfully improved the department staff’s effort in conducting hemodialysis treatment and their knowledge of dialysis water quality and safety, thereby ensuring a safe hospital environment.