運用條碼科技改善病理組織檢體漏送之方案

A Scheme for Improving Missed Deliveries of Pathological Tissue Specimens Using Barcode Systems

鄭碧芬(Pi-Fen Cheng)；王婇帆(Tsai-Fan Wang)；王姮樺(Heng-Hua Wang)；陳繪竹(Hui-Zhu Chen)

條碼科技 ； 病理組織 ； 檢體漏送 ； barcode systems ； pathological tissue ； specimens missed

志為護理-慈濟護理雜誌

21卷6期（2022 / 12 / 01）

63 - 74

繁體中文;英文

病理組織送檢過程若有錯誤或異常，將會影響病人安全及後續的醫療照護品質。本院於2018年12月發生病理組織檢體漏送之異常事件，經現況分析確立問題為無病理組織檢體送檢單置放規範、無病理組織檢體送檢監控流程、無特定協同採檢人員、護理師未檢視病歷單張等，故引發改善動機；解決方案為設置病理組織檢查送檢單置放籃，由書記每日確認單張、由專科護理師協同主治醫師採檢病理組織、核對並完成病理組織檢查送檢單、排定單位內專責護理師檢查病歷單張、導入Barcode病理送檢系統、排定教育訓練課程，到各單位宣導Barcode病理送檢系統。經專案改善後，追蹤2019年2月1日至2020年4月30日，降為0件，達專案目標，希冀藉由全面條碼化病理組織檢體送檢等流程，杜絕檢體漏送率，以維護病人診斷即時性之就醫權利。

If there is an error or abnormality in the pathological tissue examination process, it may affect the safety of the patient and the quality and timely delivery of subsequent medical care. An abnormal incident of pathological tissue specimen missed delivery did occurred in this hospital in December 2018. The current situation analysis has established the following problems: there is no pathological tissue examination submission form placement specification; no pathological tissue specimen submission monitoring process; no specific collaborative inspection personnel; and a failure to check the Medical records leaflet. These issues triggered the motivation for improvement. Solutions include: setting up a specific location to place the pathological tissue inspection submission form; the secretary will confirm the leaflet every day, the nurse practitioner and attending physicians will collect pathological tissues together then check and complete the pathological tissue inspection submission form; scheduling of specific nurses to check the medical records leaflet and import into the Barcode pathology examination system; schedule Barcode pathology examination system education and training courses, and promotes to all units. After improvement resulting from the project, tracking from February 1, 2019 to April 30, 2020, showed issues had reduced to 0, thus reaching the project goal. It is hoped that through the comprehensive barcoded pathological tissue specimen delivery process, the rate of missed specimens will be eliminated, and the patient's right to receive immediate medical treatment and diagnosis will be maintained.

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