A Novel Swiss Cheese Model-Based Safety Chain Management System for Central Sterile Supply Department

Jing Che; Qiongrong Liu; Xiuhui Wu; Yunlei Li; Min Li

doi:10.11910/j.issn.2791-2043.2025.4.06

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A Novel Swiss Cheese Model-Based Safety Chain Management System for Central Sterile Supply Department

TECHNOLOGICAL INNOVATION | Updated：2026-04-21

- A Novel Swiss Cheese Model-Based Safety Chain Management System for Central Sterile Supply Department
- Sterile Supply Vol. 4, Issue 4, (2025)
- Affiliations：
  
  Jingmen Central Hospital Affiliated to Jingchu University of Technology, Jingmen 448000, Hubei, China
- Author bio：
  
  Jing Che
  Qiongrong Liu at 48651387@qq.com
- Funds：
- DOI：10.11910/j.issn.2791-2043.2025.4.06
  CLC：
- Published：15 December 2025
- Accepted：
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Che Jing,Liu Qiongrong,Wu Xiuhui,et al.A Novel Swiss Cheese Model-Based Safety Chain Management System for Central Sterile Supply Department[J].Sterile Supply,2025,04(04):278-288.
DOI：

Che Jing,Liu Qiongrong,Wu Xiuhui,et al.A Novel Swiss Cheese Model-Based Safety Chain Management System for Central Sterile Supply Department[J].Sterile Supply,2025,04(04):278-288. DOI： 10.11910/j.issn.2791-2043.2025.4.06.

摘要

Abstract

Objective

This study aimed to develop and implement a safety chain management system for the Central Sterile Supply Department (CSSD) based on the Swiss Cheese Model.

Methods

Based on literature analysis and case studies

a safety chain management system was developed by integrating the multi-layer defense concept of the Swiss Cheese Model into CSSD management. The system encompassed ten key components related to processes

equipment

personnel

and supervision. To evaluate its effectiveness

comparisons were made before and after the intervention in terms of instrument cleaning efficacy

standardized acceptance rate of high-risk instruments

sterilization qualification rate

and adverse event reporting rate.

Results

Following the intervention

the qualified rate of instrument cleaning increased from 99.74% to 99.94% (

0.001)

the standardized acceptance rate of high-risk instruments rose from 99.6% to 99.81% (

0.001)

and the sterilization qualification rate improved from 99.56% to 99.90%. Notably

the number of sterilization process interruptions caused by incomplete instrument drying decreased from 4 to 1

positive biological monitoring results declined from 2 to 1

wet packages were reduced by 2 cases

and cycle interruptions due to equipment failure decreased by 3. In addition

the adverse event reporting rate increased markedly from 24.49% to 75.00% (

0.001).

Conclusion

The proposed safety chain management system effectively reduces the risk of healthcare-associated infections and improves the quality of instrument reprocessing in the CSSD. It also offers a novel theoretical framework and practical guidance for advancing safety management practices in the CSSD.

关键词

Keywords

references

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