- 期刊
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
摘要
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爲1.68%，遠高於同儕醫院，分析原因爲：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。
並列摘要
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.