建立組織切片檢體運送處置流程方案

放射線介入檢查後檢體的收集與運送是一項很重要的工作，任何錯誤都會影響病患診斷；治療與健保給付。統計本單位2006/9~2007/8有1153件檢體送出10件組織切片檢體遺失，遺失率為0.87%，遺失檢體必需重新安排檢查，造成病人重複曝露檢查風險，且對本院醫療品質失去信心；也造成工作時數；技術醫材費之損耗。分析其原因包括在政策面；執行的程序步驟；軟硬體設備；工作人員等，都需改進。因此著手進行改善方案，針對過程面制定病患切片檢體運送標準流程；檢體收集之範本及安排同仁教育訓練；加強宣導。於2007年12月17日至21日及2008年1月28日至2月1日，共收集52件切片檢查案例，檢體遺失率降為0%，檢體標示包裝正確率98.12%；檢體運送流程完整性提升至98.08%，同仁對專案滿意度達96.3%。

The collection and delivery of the specimen after tissue biopsy is an important work in the department of radiology. For the duration of 2006/9~2007/8, we found 0.87% of specimens lost during collection and delivery, which resulted in repeating examinations and the waste of medical resources. Three leading causes of specimen loss were: (1) non-standardarized packaging, (2) poor marking on the specimens, (3) lack of standardized specimen delivery flow path. A project was developed to improve these problems during 2007/11~2008/1.We established the standards for tissue biopsy specimen delivery process including how to collect and wrap the specimen correctly. We carried out staff education programs of these standard procedures and communicated these changes with every related coworker. Finally, the rate of specimen loss was 0%and the correct rate of collected and wrapped specimen was 98.12%; the complete rate of specimen delivery process was 98.08%; and the satisfactory rate of this project was 96.3%.