Hu Pao-Hsueh, Hu Hsiao-Chen, Huang Hui-Ju, Chao Hui-Lin, Lei Ei-Fang
Operating Room, Cathay General Hospital, Taiwan, ROC.
Department of Nursing, Cathay General Hospital, Taiwan, ROC.
Hu Li Za Zhi. 2014 Apr;61(2 Suppl):S50-9. doi: 10.6224/JN.61.2.50.
BACKGROUND & PROBLEMS: Because surgical pathology specimens are crucial to the diagnosis and treatment of disease, it is critical that they be collected and transported safely and securely. Due to recent near-miss events in our department, we used the healthcare failure model and effect analysis to identify 14 potential perils in the specimen collection and transportation process. Improvement and prevention strategies were developed accordingly to improve quality of care.
Using health care failure mode and effect analysis (HFMEA) may improve the surgical specimen transportation process and reduce the rate of surgical specimen rejection.
Rectify standard operating procedures for surgical pathology specimen collection and transportation. Create educational videos and posters. Rectify methods of specimen verification. Organize and create an online and instantaneous management system for specimen tracking and specimen rejection.
Implementation of the new surgical specimen transportation process effectively eliminated the 14 identified potential perils. In addition, the specimen rejection fell from 0.86% to 0.03%.
This project was applied to improve the specimen transportation process, enhance interdisciplinary cooperation, and improve the patient-centered healthcare system. The creation and implementation of an online information system significantly facilitates specimen tracking, hospital cost reductions, and patient safety improvements. The success in our department is currently being replicated across all departments in our hospital that transport specimens. Our experience and strategy may be applied to inter-hospital specimen transportation in the future.
由于手术病理标本对疾病的诊断和治疗至关重要，确保其安全收集和运输至关重要。鉴于我们科室近期发生的几起未遂事件，我们运用医疗失效模式与效应分析来识别标本收集和运输过程中的14个潜在风险。相应地制定了改进和预防策略以提高医疗质量。
运用医疗失效模式与效应分析（HFMEA）可能会改善手术标本运输过程并降低手术标本拒收率。
修订手术病理标本收集和运输的标准操作程序。制作教育视频和海报。修订标本核查方法。组织并创建一个用于标本追踪和标本拒收的在线即时管理系统。
新的手术标本运输流程的实施有效消除了已识别的14个潜在风险。此外，标本拒收率从0.86%降至0.03%。
该项目用于改善标本运输过程，加强跨学科合作，并完善以患者为中心的医疗体系。在线信息系统的创建和实施显著促进了标本追踪、降低医院成本以及提高患者安全性。我们科室的成功经验目前正在我院所有运输标本的科室推广。我们的经验和策略未来可能会应用于医院间的标本运输。
