降低手術檢體退件率

Strategies to Reduce Surgical Specimen Rejection Rate

10.6530/YYN/2015.3.03

吳雪紅(Hsueh-Hung Wu)；魏玉芳(Yu-Fang Wei)；闞秋萍(Chiou-Ping Kan)；李淑燕(Shu-Yen Li)；林佳慧(Chia-Huei Lin)

手術檢體 ； 退件率 ； 病人安全 ； 手術全期護理 ； surgical specimen ； rejection rate ； patient safety ； perioperative nursing

源遠護理

9卷1期（2015 / 03 / 01）

37 - 44

繁體中文

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。

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.

1. Layfield, J. L.,Anderson, G. M.(2010).Speci-men labeling errors in surgical pathology an 18-month experience.The Anatomic Pathology,134,466-470.
2. Nakhleh, E. R.(2008).Patient safety and error reduc-tion in surgical pathology.Archives of Patholo-gy & Laboratory Medicine,132(2),181-185.
3. Steelman, M. V.,Graling, R. P.,Perkhounkova, Y.(2013).Priority patient safety issues identified by perioperative nurses.Association of Periop-erative Registered Nurses,97(4),402-416.
4. 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。
5. 行政院衛生署（2012）．101-102年度醫療品質及病人安全工作目標及執行策略．取自http://www.doh.gov.tw/big5/Contentasp?cid=135
6. 呂先玉,王麗卿,鍾正姮(2009)。運用JCAHO品管步驟降低手術標本送檢異常發生率。醫療品質雜誌，5(3)，83-94。
7. 李佳倫,蕭文琪,蔡雅齡,孫麗珍(2011)。降低某內科病房檢體退件率之專案。高雄護理雜誌，28(1)，23-34。
8. 林金蓮,康秀雲,楊君菁(2011)。降低病房檢體異常之改善專案。長庚護理，22(1)，73-83。
9. 財團法人醫院評鑑暨醫療品質策進會（2011a）．新式評量方法簡介．取自http://www.tjcha.org.tw/FrontStage/page.aspx?ID=55 BF4438
10. 財團法人醫院評鑑暨醫療品質策進會（2011b）．手術安全把關執行手冊．取自http://www.kmuh.org.tw/www/Administration/patient_safe
11. 陳惠君,黃小芬,劉曾珊,葉依雅,沈永釗,蔡麗紅(2012)。條碼科技於改善護理檢體採集標示錯誤之成效。澄清醫護管理雜誌，8(1)，56-64。
12. 黃素馨,陳怡芬,黃聖淑,羅維仁(2012)。運用專案改善提升手術室組織檢體運送完整性。安泰醫護雜誌，18(3)，63-78。
13. 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。

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