Analysis and Risk Management of 574 Surgical Instruments Surface Change Test
WANG Hongxu1a，GUO Dawei1b，LIU Dongyan1c，GUO Wei1a，SUN Lin2，ZHOU Zhuo1a
1. a. Operation Room| b. Department of Clinical Medical Engineering| c. Department of Central Sterile Supply, Beijing Shijitan
Hospital, Capital Medical University, Beijing 100038, China|
2. Department of Urology, The First Hospital of Fangshan District, Beijing 102400, China
Abstract：Objective The surgical instruments at the hospital were tested to understand their quality status, and the problems
discovered in tests were analyzed to formulate corresponding risk management measures, so as to guarantee the surgical instrument
quality and surgical safety. Methods The 42 in-service instrument sets and 574 instruments used in the operating room were tested,
and the 9 kinds of instrumental surface changing were counted according to the risk level and degree of damage. Results A total of
219 surgical instruments were detected with surface changes, accounting for 38%. And the most common surface change type was
silicate discoloring (n=61). Then, the Five-whys method was applied to analyze and find out the fundamental cause of instrumental
surface change, and formulate risk management measures for risk avoidance, loss control and risk transfer. Conclusion Based on
surgical instrument quality tests and the risk level-based counting strategy, it is discovered that the surgical instruments have poor
overall quality at the present stage. It is of certain reference significance to analyze the cause of instrumental surface changes and
formulate the risk management strategy, so as to enhance the instrumental quality and reduce the surgical risk.
