目的：由於手術器械包盤中多件器械打包錯誤、內容物不完整、包盤過期等問題，導致手術無法順利進行、手術成本提升；因此本研究期望透過供應中心手術器械包盤處理作業程序之改善，降低手術器械包盤管理中的多件器械打包錯誤、內容物不完整、包盤過期等情況。方法：運用品質管理方法，提出七項改善項目衡量準則，設定器械規格及高故障器械備品，制訂作業流程（如器械報廢請購、異常回報、器械送修、遺失紙卡印章、更改包裝或滅菌方式、包盤使用時再滅菌），舉辦在職教育等，以專案進行供應中心外科器械包盤管理之改善計畫。結果：手術器械包盤中的多件器械打包錯誤率由1.2% 降至0.5%，內容不完整率由7.4% 降至1.7%，包盤過期率由16.7% 降至7.3%，每月成本耗費減少18,935 元。結論：專案實施一年半之後已達專案目標且其效益穩定，未來可考慮建置數位自動化系統以進行後續器械管理。

Objectives: This study reviewed the process of assembling surgical instrument trays in the central supply room in an effort to reduce packing error of multiple instruments, the missing instruments, and overdue instrument for surgical use. Methods: This study which adopted quality control and a cause-and-effect diagram provided seven criteria for an improvement plan for assembling surgical instrument trays. Results: The packing error of multiple instruments was reduced from 1.2% to 0.5%, the missing instruments error was reduced from 7.4% to 1.7%, the overdue instrument for surgical use error was reduced from 16.7% to 7.3%, and $18,935 was saved per month. Conclusions: Efficacy was achieved after 18 months and remained stable. In the future, a digital autonomous monitoring system should be considered for managing surgical instrument trays in the central supply room.