急診室檢體錯誤率之改善方案

A Project on Reducing Errors in Specimen Collection in the Emergency Department

檢體採集和運送任一環節失誤都將影響病人診斷、治療時效性，甚至危及病人安全。統計2010年4－6月本院急診室檢體退件率為1.68%，遠高於同儕醫院，分析原因為：無檢體採集及運送標準作業流程；護理師檢體採集知識與技能不足且未核對及標示檢體；傳送人員延誤或未以檢體盒傳送導致檢體或檢驗單遺失；欠缺稽核機制等。經改善方案：制定「檢驗試管、容器一覽表」、「急診檢體採集及運送作業指導書」；安排「防止檢體錯誤守門人」之教育訓練；增購檢體傳送盒及計時器；制定稽核制度。專案實施後，統計2010年10－12月檢體退件率降至0.48%，達成專案目的，減少病人再次扎針痛苦、如期獲得報告接受治療，確保急診病人安全及醫療照護品質。

Errors occurring during specimen collection or delivery can cause patient misdiagnosis, patient care delay and even devastating consequences in patient safety. The specimen rejection rate in the emergency department of a hospital in Taiwan was 1.68% from April to June, 2010, much higher than those of other same-scaled hospitals in the area. Through cause analysis, the identified problems were a lack of standard workflow for specimen collection and delivery; nurses' insufficient knowledge and skills about specimen collection, verification and labeling of specimen; delay in specimen delivery because of either loss of specimen or loss of specimen requisition form without using a delivery box; and lack of a monitoring system. An improvement project included making a specimen collection chart for correct use of specimen containers, creating a protocol for specimen collection and delivery, holding an education program for prevention of specimen error, purchasing more delivery boxes and timers, and designing a monitoring system. After the project was implemented, the turn-down rate of specimen decreased to 0.48% from November to December, 2010. The goal of the project was achieved with decreased patient suffering from unnecessary, repeated blood-drawing; the test report was obtained within the correct timeframe, which helped to ensure patient safety and quality of care in the emergency department.