為避免影響病患安全、醫師判讀及治療方針，本文旨在利用品管方式改善手術室組織病理檢體送檢，以降低檢體重送率。本專案首先利用手術室查檢表，收集退件組織病理檢體95 案件(3.2%)，分析造成檢體重送的原因，並於實施相關改善解決辦法後，每月檢體重送率下降至0.5 ﹪以下，達到專案成立目標。希望藉此經驗分享能作為改善檢體送檢之成功案例參考依據。

In order to ensure patients' safety and not affect physicians' treatments, the objective of thisstudy was to reduce the specimen processing re-delivery rate in the operating room. First,we useda newly designed checklist to collect data on 95 cases (3.2%) which were specimens subject to redelivery,and then analyzed the reasons for re-delivery. After a quality improvement method wasimplemented, the specimen re-delivery rate dropped to 0.5%, which achieved the goal for qualityimprovement efforts. This project can serve as a successful model of process reengineering inspecimen processing delivery.