降低病房檢體異常之改善專案

Reducing the Number of Abnormal Specimens

為迅速確實、執行檢體採集與送檢，將檢體退件數降到最低，減少醫療資源浪費，避免延誤病情，故以「病房檢體異常登錄表」為工具，統計2006年1月到12月檢體異常件數共380件，每月異常件數最多35件，最少27件。依柏拉圖80/20法則分析其主要異常原因有檢體不足、未標示姓名、容器錯誤、檢體未簽名、缺檢體、檢體與檢驗單姓名不符、開錯單或缺單。經由文獻查證運用ISO品質管理系統原則及特性，建立標準作業流程，制定病房檢體採集與送檢流程圖、製作檢體採集指引本；並加強宣導及舉辦在職教育訓練等改善措施後，持續監測2007年7月到2007年12月，除8月份異常件數6件外，其他檢體異常件數均降為每月5件以下，已達本專案改善檢體異常及提供完善服務之目的。

In order to accurately and promptly collect and submit specimens, reduce the number of returned specimens, and avoid the waste of medical resources and delay of medical treatment, we used an “Abnormal Specimens Entry Sheet” as a tool to calculate the number of abnormal specimens from January 2006 to December 2006. A total of 380 abnormal specimen cases were identified during that period. The number abnormal specimens per month ranged from 27 to 35 cases. According to the 80/20 rule of Plato, the most common abnormalities were insufficient specimens, unlabelled specimens, container error, unsigned specimens, missing specimens, incorrect match between a specimen and a test, and missing or incorrect forms being used. Using the ISO quality control technique, a standard operation procedure was developed. A submission-for-inspection flowchart guidelines were developed. We advocated and provided training programs. After the improvement measure, continuous monitoring from July 2007 to December 2007 showed that the number of the abnormal specimens was less than 5 per month with 1 exception of 6 cases in August 2007. The projects reached the goal of reducing the number of abnormal specimens.