降低送檢檢體錯誤率之方案

A Project to Reduce Mistakes in Collecting Specimens

檢體的收集送檢是護理工作中重要的一項，其過程中任何一個步驟的失誤將影響到病患的診斷與治療，增加工作人員的負擔及醫療成本之浪費。本單位自民國91年4月至7月間，送檢檢體的總件數為3,382件，檢體錯誤共43件，錯誤率為1.27%。分析其主要要因有：（1）護理人員對檢體收集程序及注意事項之相關知識不足、（2）檢驗單之處理程序步驟不合宜、（3）血液檢體置放盒不適用、（4）檢體收集一覽表查詢不易。本專案係運用持續性品質改進之PDCA過程執行改善，針對問題從人員、設備、程序三方面制定策略。此方案實行之後，發現送檢檢體之錯誤率由1.27%下際為0.49%，進步率為61.4%，目標達成率為101.3%。這個改善方案不僅降低了送檢檢體之錯誤率，設備上的改善更提高了工作人員之方便性與滿意度。

Specimen collection is an important task of nursing care. Any failure to collect the whole missing of a specimen may affect diagnosis and treatment. It will also increase the workloads of staff and the cost of medicines. From April to July 2002, a total of 3,382 specimens were collected in Al 12 ward in Taipei Veterans General hospital. There were 43 wrong specimens, 1.27% of the total. Analysis showed that the reasons for the error were as follows: (1) The level of knowledge about the test tubes and about the volume of specimens was low. (2) The procedure for dealing with application from was not appropriate. (3) The box in which specimens were kept was not appropriate. (4) The checklist was bad. The PDCA process used in this project reduced the rate of wrong specimens. The strategy was designed with three dimensions: stall, facilities, and procedure. After it was implemented, the rate of wrong specimens dropped from 1.27% to 0.49%, the improvement rate was 61.4%, and the rate of achievement was 101.3%. This project not only reduced the rate of wrong specimens, but also made the process easier and more safisfying for stall.