背景:手術病理檢體是病人正確診斷與治療的重要依據，採集送檢每一環節皆不可有誤。鑑於單位手術檢體的幾近錯失（near-miss）事件，藉由醫療失效模式與效應分析，評估病理檢體採集送檢流程之風險，確認本院在流程仍有14個潛在錯失因子，故發展改善策略及建立防範措施，以提升醫療服務品質。目的:採用HFMEA（failure mode and effect analysis）改善手術室病理檢體採集送檢流程及降低病理檢體退件率。解決方案:透過修訂手術室病理檢體送檢標準流程、製作光碟教學影片、檢體採集送檢海報、修定手術檢體送檢稽核辦法、規劃病理退件資訊化追蹤機制以及線上檢體即時動態管理平台。結果:執行改善措施後，高風險因子由14個降為0個，病理檢體退件率由0.86%降為0.03%。結論:本專案藉由流程的改善與跨團隊間的合作，落實以病人安全為中心的醫療照護。可知資訊系統的建置及整合性的運用，不但能即時有效監控檢體之流向，降低人力之耗費，對病人安全的把關更是無價。目前本院手術病理檢體之成功經驗，已平行展開至全院各送檢單位，未來將擴及院際檢體之轉送。

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. Purpose: Using health care failure mode and effect analysis (HFMEA) may improve the surgical specimen transportation process and reduce the rate of surgical specimen rejection.Resolutions: 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.Results: 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%.Conclusions: 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.