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Results: Four samples were taken to culture from inner tube and outer tube of a endoscope. Two samples did not meet the standards of high-level disinfection procedures. After the infection control team involving in investigation and analyzing these results, we improved the clean procedure and added a drying equipment in endoscopic cabinet. The incident was terminated. Conclusions: The incident unveiled the clean and disinfection procedure should be implemented for the safety and quality ofdoi:10.1016/j.jmii.2015.02.627 fatcat:o7zknv2vyjdkfa4tq7sjonayvm