1998年 7～ 9月 ,我区某卫生所因玻璃注射器消毒不规范 ,导致 5人肌肉注射后感染偶发分枝杆菌。为了解原因 ,我们于 1999年 1月 17日进行现场调查 ,调查情况报告如下 :1　材料与方法查阅该卫生院 7～ 9月份处方 ,查出有肌肉注射史的病人 ,按预先设计的个案调查表 ,对反映注射后 From July to September 1998, some clinics in our district were disinfected due to non-standard glass syringes, which resulted in the infection of Mycobacterium fortuitum in 5 patients after intramuscular injection. In order to understand the reasons, we conducted a field survey on January 17, 1999. The investigation report is as follows: 1 Materials and methods The hospital from July to September prescriptions to detect the history of intramuscular injection of patients, according to pre-designed case studies Table, after reflection on injection