異體骨或韌帶移植者非手術室常見手術，然而執行出現疏失可能導致感染危險影響病人安 全。現況發現主要原因為未舉辦在職教育、無製訂標準作業流程及規範、缺乏動線擺設規劃及無 監控作業，讓人員對捐贈作業感到不熟悉，引發專案改善動機。改善方案有：舉辦教育訓練、建 立捐贈骨骼及韌帶標準作業手冊、製作準備用物明細、修訂捐贈登錄本及定期稽核機制等。方案 介入後護理人員捐贈骨骼及韌帶執行作業認知率由81.5% 提升到100%，捐贈作業時間由14.5 小 時縮短到12 小時內，骨骼及韌帶細菌培養陽性率降為0%。本專案結果讓醫院對於器官勸募過程 中在捐贈骨骼及韌帶成功率提高；單位護理人員與專科醫師手術過程更具有合作共識，提升了工 作效率，重要是完成捐贈者遺願並確保日後受贈病人的安全權益。

Donation of bone and ligament is rare in the operating room. The recognition rate of the donation and transplant operation performed by nursing group is only 85%. The transplant operation time is 14.5 hours, and the positive rate of bacterial culture obtained from bone and ligament are 7.1% and 4.1%, respectively. In order to improve these performances, we need to find out what causes nursing group members unfamiliar with the donation operation. The possible causes include: the lack of in-service education and monitoring mechanism, undefined standard operation processes and regulations, and poor arrangement of operational instruments. Therefore, our program aims to improve these conditions by organizing education and training, writing a standard operating manual, producing preparation item lists, amending the donations lists, and regulating the auditing mechanism. After executing the program, the transplant operation time reduced to 12 hours from 14.5 hours, the recognition rate increased from 81.5% to 100%, and the bacterial infection rate of bone and ligaments both reduced to zero. In conclusion, our education program provides high success rate of bone and ligament donation, good cooperation of team work, and efficient work performance. The most important part is to complete donors’ wishes and ensure the recipients’ safety.