背景:詳細的護理交班內容，可以提升護理照護的完整性。本研究收案單位多次接獲病房反應病人自恢復室返回病房，曾有胸腔引流管阻塞及假牙鬆脫甚至遺失等不良事件，共計22件。為維護病人安全及提升單位護理人員交班品質，故激發成立專案小組，藉由現況資料的收集來擬定改善的方案，來改善交班作業的缺失，避免因一時疏忽影響病人安全，同時提昇個別化的整體護理照護。目的:提升恢復室護理人員執行術後病人交班作業完整性達91%。解決方案修訂麻醉後恢復期護理標準作業規範、製作恢復室術後交班指引、舉辦在職教育課程及建立定期稽核機制。結果:恢復室護理人員執行術後病人交班作業完整性由改善前的73.5%提升至98.6%。結論:術後完整性的交班，可增進團隊間的溝通並能提供病人持續性的護理，進而提升護理照護品質。

Background & Problems: Detailed descriptions of nursing shift tasks are necessary to achieve comprehensive nursing care. The 22 cases of postoperative recovery ward error reported by our unit included chest tube obstructions, lost dentures and other nursing issues. To improve patient health and nurse shift quality, our unit established an ad hoc group to collect data helpful to overcoming problems attributable to nurse shift changes. We aimed to better nursing care by facilitating individualized patient care and avoiding accidents detrimental to patient safety. Purpose: This project was designed to raise the rate of 100% completion of nursing shift-change tasks to 91% of postoperative recovery room nurses.
Resolution: Newly revised operating standards regarding the recovery period after anesthesia established guidelines for a regular audit mechanism and in-service education programs for recovery room shift tasks.
Result: Full completion of shift tasks in the postoperative recovery room improved from 73.5% to 98.6% of nurses. Conclusion: Comprehensive completion of postoperative nursing shift-change tasks increases communication between team members, provides continuous care for patients, and enhances overall nursing care quality.