降低手術檢體退件率之專案

A Project for Reducing Specimen Rejection Rate in the Operating Room

檢體退件會造成病人診斷與治療延誤，增加醫院成本及人力負荷。現況發現本單位檢體退件率高，分析主要原因為護理師未核對檢體標籤、檢驗單及不熟悉檢體處理程序、助理員檢體未依規定登記及擺放、未定期舉辦在職教育、未制訂檢體處理程序因解釋病情中途取走、規範未整合、檢體冰箱未上鎖等問題，基於病人安全考量及院區醫療品質指標要求零錯誤，期望降低手術檢體退件率。因此，進行解決方案：舉辦檢體處理及運送作業之相關在職教育、修訂檢體送檢作業流程內容、製作手術檢體送檢作業手冊、進行檢體存放設備的檢視及建立標準稽核機制等措施。方案執行後檢體送檢正確率由79.2%提升100%，退件率0.48%降低至0%。讓團隊成員高度參與，能改變想法及行為模式，防範醫療錯誤，提升病人安全。

Specimen return will cause delay in diagnosis and treatment for patients. It also increases hospital cost and manpower burden. We found that nurses did not check specimen labels as well as the inspection lists and they were not familiar with the handling procedures of specimen. The assistants did not follow the rules to register the specimen lists and put the specimen at the right places. In addition, they did not hold the in-service training regularly. Furthermore, they did not set up the procedures of the archived specimen which was taken away before the procedure completed because of disease explanation. The standard of specimen procedure was not integrated. They did not lock the specimen refrigerator and lack of privacy and security during specimen transportation. Therefore we proposed following solutions: holding in-service trainings, revising the standard operating procedures of specimen examination, making surgical specimen examination procedure manuals, examining the specimen storage devices, and establishing standard auditing systems. After executing the programs, the accuracy rate of specimen examination increases from 79.2% to 100% and the surgical specimen return rate reduces from 0.48% to 0%. Clinical team has a sense of participation and is willing to change their thoughts as well as behaviors to reduce medical mistakes and increase patient safety.