基于事故树模型的布鲁氏菌病实验室获得性感染事件分析

Analysis of laboratory-acquired infection accidents of brucellosis based on FTA

目的探讨事故树分析法在布鲁氏菌病实验室获得性感染事件中的应用。方法以某大学实验室布鲁氏菌感染造成28人受伤作为顶事件,建立事故树模型并对其发生原因进行分析。结果布鲁氏菌病实验室获得性感染的发生存在52种可能的途径及7种预防方法,对其结构重要度进行分析,找出了导致事件发生的薄弱环节。违规购买山羊、山羊未接种疫苗、实验前未对山羊进行卫生检疫、没有使用个人防护装备、使用有故障的个人防护装备、没有正确佩戴个人防护装备、选择不合适型号的个人防护装备、标准操作程序(SOP)不健全是顶事件发生最重要的影响因素。结论事故树分析法能够有效对布鲁氏菌实验室获得性感染进行预防分析,为实验室制定相应的预防措施提供可靠的决策依据。

Objective To explore the application of Fault Tree Analysis(FTA)method in the laboratory-acquired infection accidents of brucellosis.Methods The incident of laboratory-acquired infection accidents of brucellosis in a university was selected as the top event to set up the fault tree diagram.FTA method was used to analyze the causes.Results There would be 52 possible ways and 7 kinds of prevention methods in laboratory-acquired infection accidents of brucellosis.The analysis of the important degree of the structure was analyzed to find the weak links that led to the incident.Improper purchase of goats,failure to vaccinate goats,failure to conduct health quarantine on goats prior to experiments,failure to use personal protective equipment,utilization of faulty PPE,failure to wear PPE correctly,selection of unsuitable PPE models and poor laboratory operating procedures(SOP)were the most important influencing factors of the occurrence of top events.Conclusion Through FTA method,preventing accidents in laboratory-acquired infection accidents of brucellosis can be effectively analyzed,to provide a reliable basis for the laboratory to make corresponding preventive measures.