降低手術檢體退件率

手術檢體的即時判讀與回饋有利臨床診斷及擬定治療方針，是病人安全重要指標。本單位2012年第1至3季手術檢體退件率平均為0.17%，第4季驟增至1.08%，超過院內指標閾值（0.18%），亦高於財團法人全國認證基金會之檢體退件率（0.5%）指標的2.16倍。為降低手術檢體退件率、提升手術檢體收集及送檢正確率，專案小組透過修訂手術檢體收集及送檢標準作業流程、拍攝教學示範影片、製作檢體收集及送檢流程海報、規劃在職教育課程、並建立稽核制度等改善措施實施後，手術檢體退件率由1.08%有效降低至0.04%，手術檢體收集正確率由80.2%提升至96.0%，手術檢體送檢作業正確率由78.8%提升至97.0%，有效維護醫療品質確保病人安全。

關鍵字

手術檢體；退件率；病人安全；手術全期護理

並列摘要

This article describes the project on improvement in the quality of intraoperative specimen collection and examination, and reduction of the rejection rate. Timely interpretation of the surgical specimen during operation is a critical index for patient safety in decision making for clinical diagnosis and therapy. The specimen rejection rate at the department was stable at 0.17% from January to September 2012; however, it increased to 1.08% from October to December, which was higher than the hospital standard of 0.18% and the Taiwan Accreditation Foundation (TAF) standard of 0.5%. The project team identified the possible causes that included Standard Operation Procedure (SOP) which was not properly executed, insufficient knowledge on specimen collection and examination, and lack of auditing. The team reviewed and edited the SOP, conducted staff training, and developed an auditing system. The rejection rate reduced from 1.08% to 0.04%. The rate of the quality of specimen collection improved from 80.2 % to 96%, and examination accuracy rate improved from 78.8% to 97%. This project effectively improved quality of care and patient safety.

並列關鍵字

surgical specimen ； rejection rate ； patient safety ； perioperative nursing

參考文獻

楊明菊、王慧儒、陳小萍、楊慧珍（2009）．建立組織切片檢體運送處置流程方案．榮總護理，26（3），228-236。doi:10.6142/VGHN.26.3.228

Layfield, J. L., & Anderson, G. M. (2010). Speci-men labeling errors in surgical pathology an 18-month experience. The Anatomic Pathology, 134, 466-470. doi:10.1309/ACJPHLQHJOS3D-FJK

古雪鈴、王拔群、陳雅惠（2005）．應用品管方式降低手術室組織病理檢體重送率．輔仁醫學期刊，3（2），63-67。