本專案旨在探討病房儀器物品遺失率高之原因，藉由有效措施改善儀器物品遺失情形，以保障病人安全提升醫療照護品質。專案小組收集本病房2009年12月至2010年10月共計11個月之儀器物品遺失資料，發現儀器物品遺失率高達2.6%，經分析其主要原因有：點班未完成即交給下一班人員、新進人員不瞭解點班流程、病人轉床後未清點用物、儀器物品數量不確定等項。經制定本單位點班作業規則、修訂儀器物品點班本、舉辦單位教育訓練、建立護佐人員輔助歸位機制、儀器物品標示本單位標幟、修訂護理人員交班單及儀器物品重新清點與編號等方案介入後，使得病房儀器物品遺失率由2.6%降至0%，提升儀器物品管理效能，確保病人安全與照護品質。

This project is trying to describe and explain the cause of frequent loss of equipment in a medical ward, and try to prevent it, in order to secure the safety of patients and increase the medical quality. The special assigned group collected 11 months of data of equipment loss from 2009 December to 2010 October, found that the losing rate is 2.6%. From the reported reason and feature of loss, we found the following common cause: 1. Equipment are passed to the next shift before counting. 2. New staffs are now familiar with the procedure of counting. 3. No counting is performed when patients are transferred to other wards. 4. True numbers of equipment are not recorded. Through the establishment of the procedure of counting, revision of equipment's logbook, staffs' education, establishment of a mechanism with the aid reset by nursing assistants, unit's sticker of equipment, revision of shift changing logbook and recounting and numbering of equipment, the losing rate has been reduced from 2.6% to 0%. This project guaranteed the efficient management of the ward's equipment.