血液透析中良好的逆滲透（reverse osmosis, RO）水質，是確保病人安全的基本要素，本單位於 2016 年 7 月 22 日 RO 水質監測菌落數異常，引發改善專案的動機。現況分析確認主要問題為：RO 管路消毒內容規範不明確、缺乏檢測高濃度漂白水之工具、採水點出水口設計不良、缺乏稽核機制及人員認知不足。藉由跨團隊會議、標竿學習他院之 RO 系統管理、修訂管消規範、辦理教育訓練、購置消毒濃度監測工具及更換易於消毒之採水口、制訂管路消毒查核表等措施，使 RO 水質監測菌落數＞50 cfu/ml 之異常率由 20％降至 0％、RO 管消流程之正確率由 66.7％提升至100％、RO 菌落數監測採水流程正確率由 83.3％提升至 100％。本專案結果有效解決 RO 水質問題，達到提升透析病人安全之目的，可供相關單位參考。

Acceptable quality of water filtered with reverse osmosis (RO) is a critical component for ensuring the health of hemodialysis patients. A routine water quality monitoring exercise conducted on 22 July 2016 found abnormal amounts of bacterial colonies and prompted the improvement program. Analysis of this assessment found that the primary issues were: ambiguous standards for RO conduit disinfection, lack of instruments to detect a high concentration of bleach, defective design of the water outlet for the water source, absence of auditing mechanisms and awareness among personnel. Remedial measures taken included: group meetings, acquiring RO system management experience of other hospitals through benchmarking, establishing conduit disinfection protocol, holding educational training, purchasing disinfectant concentration monitors, replacing water outlet to streamline the disinfection treatment process and generating a conduit disinfection verification checklist. The aim is to produce improved RO water quality that would reduce the abnormal rate of bacterial colonies (>50 cfu/ml) from 20% to 10%, to increase the precision rate of RO conduit disinfection process from 66.7% to 100%, and to increase the precision rate of water sampling process in RO bacterial monitoring from 83% to 100%. This project has effectively resolved RO water quality issues and achieved the improvement of the safety for hemodialysis patients. Relevant units may use this study for future reference.