RESUMEN
OBJECTIVE To investigate existed or potential dangerous incidents in the daily work of sterilization and supply center, and establish countermeasures against them. METHODS The causes of dangerous incidents confirmed by nursing department from Jun 2006 to Oct 2007 were analyzed. RESULTS The most common dangerous incidents were nonstandard clinical self-prepared operation packs, non-fully cleared appliance and the non-turnoff of storage aperture. And the rate of the incidents was 18.6%, 10.9% and 9.2%, respectively. Direct dangerous incidents accounted for 72.3% and indirect dangerous incidents accounted for 27.7% in the total number of dangerous incidents. CONCLUSIONS The dangerous incidents can be reduced effectively by adopting relevant measures, enhancing risk surveillences and supervising the high-risk parts.