Abstract：Objective To investigate the potential factor of medical wet packs after sterilization by fishbone diagram and to provide related countermeasures. Methods Potential factor of medical wet packs after pulsation vacuum sterilization were analyzed by fishbone diagram from five scales, including human, machine, material, method and environment issues. Results Of 2 780 sterile packs selected, 25 cases were wet packs, accounting for 0.90%. The rate of wet packs was highest in the orthopedic operating instrument set. Medical package with packing material of cotton was less likely to be wet. Orthopedic operating instrument packs with packing material of closed container and double cotton layer were most likely to be wet. In terms of position, 10 packs(40.00%)were located at bottom layer of sterilizer, 8 cases(32.00%)were closed to inner wall of sterilizer, 5 cases(20.00%)were located at front gate of sterilizer, 3 cases(12.00%)were located at up layer of 20.00% and 2 cases(8.00%)were located at back gate of sterilizer. Conclusion Factor analysis by fishbone diagram is an intuitive way to find potential risk of medical wet packs after sterilization, and to provide evidence for countermeasures making.
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