檢體送檢的目的在於提供臨床醫師有關病人的各種檢體檢驗數據，以其做為診斷疾病、治療效果的追蹤及疾病篩檢的可靠依據。手術中取下之檢體送檢，其檢驗過程需經過相當多的環節，若其中有一環節未能按照標準程序完成，極易造成檢驗數據錯誤，進而危害到病人生命安全。另一方面，根本原因分析方法（RCA）對特定意外事件的分析被證明是非常實用，RCA是以一套系統化程序找出問題發生的根本原因，執行改善行動，避免相類似的問題重複發生，可以達到降低風險、提升安全的有效方法。本研究以北部某醫學中心為例，依其院內發生的檢體不良事件實際案例為例，利用根本原因分析方法進行回溯性分析，從執行面及制度與管理面提出改善機制。改善機制除了修正原有規範，制立一標準化手術室醫療檢體作業流程規範，並導入條碼資訊系統避免發生人工易造成的錯誤以確保檢體的正確性。改善機制實行前，手術室醫療檢體被退件率為1.52%，經實施修正的辦法後，檢體被退件率已降至0.11%。

The purpose of specimen examination is to provide clinicians reliable references in disease diagnosis, intervention follow-up, and screening. Specimens collected during a surgery go through multiple processes of transmission. Should any step deviate from standard operation procedures, it may easily result in reading errors, which further jeopardizes patient safety. Root cause analysis has been proved an effective approach in reducing risks and enhances patient safety by systematically clarify the fundamental causes of an adverse event, thereby correcting the problems to avoid recurrence of similar problems. Taking the adverse event of surgical specimen transmission of a medical center in Northern Taiwan as the subject, the study applies root cause analysis in retrospectively reviewing all relevant information and data and proposes amendments in execution, administrative process and management. The proposal modifies the original norms and establishes new standard operation procedures for the transmission of surgical specimens, while introducing the bar code technique in various processes to ensure accuracy in every step. The newly devised standard operation procedures, along with the bar code technique, have successfully reduced the rejection rate of surgical specimens from 1.52% to 0.11%.