「病人安全」議題受到世界各國重視，醫策會於2013年宣導，轉運病人標準作業程序應包含轉送風險評估、人力配置適當、設備完善與轉送流程標準，以確保訊息傳遞正確性與轉送病人的安全。本單位於2012年1月至2012年12月調查發現重症病人轉送安全異常事件共94件，引發專案小組改善動機。本專案旨在提昇急診護理人員執行急診重症病人轉送安全完整性達99%。解決方案：經文獻查證及團隊討論後，設立改善策略，包括：(1)制定轉送前檢查表。(2)修訂急診重症病人轉送安全作業標準。(3)製作氧氣容量與使用時間對照表。(4)舉辦實務性在職教育訓練。(5)設立急救專用電梯刷卡管制。(6)制定轉送技術標準審核監測計畫。重症病人轉送安全完整性由76.8%提升至99.3%。期望藉此專案分享可提供臨床護理人員轉送作業之參考，使轉送重症病人交接安全達到零異常。

Patient safety is highly valued around the world. Since 2013, the Joint Commission of Taiwan (JCT) has been promoting the standard operating procedures (SOP) of patient transferring, including risk assessment, proper staff allocation, well-equipped facility, and a transfer process standard. In 2012, the emergency department (ED) in our hospital has found 94 abnormal events of transferring critically ill patients, which motivated the medical staff to develop strategies to reduce the chance of unsafe transferring. The objective of the project is to enhance safety of transferring critically ill patients in ED to 99%. After literature review and discussions, the following strategies were introduced: 1) developing the pre-transfer checklist; 2) revising the SOP of patient transfer; 3) developing an oxygen cylinder duration chart; 4) organizing hands-on staff trainings; 5) setting up access control function at ED-only elevators; and 6) developing an audit program for SOP. The percentage of patient being safely transferred from ED to ICU has increased from 76.8% to 99.3%. We expect zero abnormality in transferring critically ill patients by sharing patient transfer SOP with nurses.