醫院有責任提供安全的醫療器材為患者服務、保障人民就醫的權利，然而，醫療糾紛中常發現，因醫療機構感染管制措施未落實，以致危害民眾生命，衍生法律責任及社會成本。本篇針對常規內視鏡微生物培養異常結果調查分析，提供消毒作業流程及學習正確的消毒滅菌方法等感染管制措施建議，藉以杜絕感染的機會，提升醫療品質。某區域教學醫院於98年10月進行每月一次的內視鏡培養檢查，採檢方式分別以「管路沖洗法」及「表面塗抹法」採檢31件消毒後的內視鏡內、外管，發現有11件內視鏡之培養結果未符合高層次消毒的標準，經感染控制小組介入調查並分析原因，在改善內視鏡儲藏櫃之清潔流程與增設烘乾設備後，終止此異常事件。藉由此次事件發現安全內視鏡的品質，除了落實清洗、消毒的流程與消毒劑的濃度檢測外，亦須考慮內視鏡存放的位置與空間潔淨度的維護。

Hospitals have the responsibility to provide safe medical equipments for patients, to protect the rights of medical treatment for the people. However, the patient's life was dangerous because medical institutions do not implement the infection control measures, and the situations were often seen in the medical disputes, they also derived liabilities and social costs. The method use "pipeline flushing method" and "the surface smudges method "on every month in October, 2009 examines 31 disinfection in the endoscopes, 11 endoscope results have discovered not to conform the high level disinfection standard. The infection control group involves investigates and analyzes the reason, after improvement endoscope safe clean flow and drying plant, terminates this unusual event. This article analyzed the abnormal bacterial culture results found in routine endoscopic cultures, it provide recommendations for infection control measures in disinfection processes, and learning proper sterilization methods, to eliminate the chance of infection, and to improve quality of care.