門診化療的安全流程是不同於住院，由於病人流量不定、治療時間短流動率大、多科處方、種類繁複等特性，若在治療作業中任一流程中出現疏失，則可能引發傷害事故；因此應對高風險作業流程作出風險評估，預先思考風險防範策略與預防行動，創造一個「毫無意外」的治療環境，確保醫療照護品質。本專案經由查檢並評估作業流程之潛在風險，分析流程不良原因，制定標準作業流程，利用資訊設備、設計輔助工具及實施在職教育等改善措施，使門診化療作業流程正確執行率達100%，提升病人滿意度達97.2%，護理人員滿意度達100%，落實病人安全於作業常規，營造以病人為中心的安全醫療環境。

The safety procedure for chemotherapy in Outpatient Department (OPD) is different from that during hospitalization, because the number of patient treated is variable, duration of chemotherapy is short, and the prescription is multi-dimensional and complicated. If there is any neglect during chemotherapy, it is likely to hurt the patient seriously. Therefore it is necessary to evaluate the risk associated with the procedure, and be prepared in advance to handle risk or crisis, in order to ensure good medical care quality and create an accident-free environment.After adopting standard operating procedure, utilizing information technology, designing aiding tools, and conducting on-the-job training to the staff, the accurate execution ratio of chemotherapy achieved 100%, and the satisfaction ratio from patient and staff achieved 97.2% and 100% respectively. It is obvious that the implementation of this proposal will help achieve a patient-centered medical environment.