某醫學中心急診室檢體退件率之改善專案

本專案的目的是針對某醫學中心急診室的檢體退件情形進行探討及改善。依檢驗科2004年1月到6月之統計資料，急診室檢體退件率為119%，是全院之冠。故單位成立「護理品質管控小組」在8月至10月期間，以「急診檢體退件原因登錄表」為工具，登錄並分析急診檢體遭退件原因，有1．檢驗單錯誤，如：開錯單、缺單或重複開單及病患資料不符；2．檢體錯誤，如：無檢體、檢體不足、凝固、溶血、容器錯誤、未貼上或貼錯病患標籤、檢體外滲；3．其他方面，如：送錯地點或誤時運送等原因。經與相關部門協調溝通後，制定「急診檢體運送標準流程圖」、「檢體容器使用說明圖表」，確實落實醫囑資訊化，公佈正確的檢體採集及送檢工作規範，加強宣導及安排人員在職教育訓練課程等，改善方案從2004年8月實施至2005年4月，平均每月檢體退件率已降到0.41%，專案目的達成。

關鍵字

急診檢體；退件率；醫囑資訊化

並列摘要

This project primarily aims to investigate and improve rejection of specimens in the emergency room (ER) of a medical center. Statistical data for 2004/01 to 2004/06 revealed a rejection rate of 1.19%, ranking first in the hospital. During August to October, using the ”recording list for the causes of ER specimen rejection” as a tool, the factors for the rejection of ER specimens was investigated. Analysis of the results showed problems such as wrong examination sheets, lack of examination sheets, repeat examination sheets, lack of patients' basic information or wrong information, lack of specimens, incorrect specimens, specimens without labeling or signification, contamination of specimens, transportation delays of sending of specimens to the wrong destinations and so on. Following discussing with relevant departments, a panel was established to monitor nursing quality, designing the standard chart of ER specimen transportation and specimens containers, to ensure the computerized of medical order, announcing the correct regulation of works, improving health education and promotion, arranging staffs to attend further education training programs and so on. The project was practiced until 94/04 and the average rejection of ER specimens has dropped to 0.41%. The goal can be achieved through quality monitoring.