手術器械清洗維護不當造成器械的損壞，直接危害到病人安全，故引發專案改善動機。經 2014 年2 月調查發現，造成手術器械不良之原因有﹕庶務員未確實檢視器械外觀及零件、未正確 選擇合適的洗滌劑及動力工具的清洗步驟不正確、對人工清洗原則及步驟( 動力工具) 不清楚、 器械維護不清楚、欠缺教育訓練、器械未排訂定期檢測保養、未建立稽核制度、無檢視器械的輔 助工具、未提供洗滌劑簡易說明。解決方案為：舉辦在職教育、製作洗滌劑適用範圍參照表及動 力工具清洗步驟圖、增購放大鏡檯燈、跨部門定期器械檢測保養、建立稽核機制。措施介入後， 手術器械不良率由42.1% 降至0%；執行正確性由73.3% 提升至98.7%；認知程度由75.4% 提升 至100%。跨團隊合作的介入確實降低手術器械不良率，進而提升手術醫療品質及保障病人手術 安全。

Improper cleaning and maintenance will cause surgical instruments and devices damage, and harm the patient safety. We surveyed the causes in February 2014 and found that the causes included improper handling of instruments and accessories, use of improper detergent, incorrect cleaning process, unfamiliarity with manual cleaning principle and process, lack of knowledge of maintaining the instruments, lack of education program, irregular maintenance of instruments, lack of standardized quality monitoring, lack of tools for examining the instruments, and lack of instruction for use of detergent. Severe steps were taken to improve the process, including holding in-service training programs, creating instruction manual for detergent use, creating flow chart for cleaning machine process, providing table lamps with magnifying power for examination, setting up an inter-department inspection system and standardized quality monitoring system. After implementation of these steps, the defective rate of surgical instruments decreased from 42.1% to 0%, accuracy of implementation increased from 73.3% to 98.7%, and recognition rate increased from 75.4% to 100%. We concluded that multidisciplinary collaboration could effectively decrease the defective rate of surgical instruments, promote surgical quality, and ensure patient safety.