抽血為臨床病理檢驗的作業之一。血液檢體經檢驗室分析後，檢驗結果提供臨床篩 檢、診斷、追蹤與治療。醫檢師在抽血過程必須確保病人的安全，在抽血後將針頭拔除 後，再用無菌棉球覆蓋於針扎處止血，並衛教病患手臂伸直，以手指加壓力棉球至少5分鐘 至不再出血為止。本案例是臨床罕見不良品質的採血針頭影響病人抽血的安全。本科汀州 門診檢驗室於2016/11/20~2016/11/30間，使用5ML，23G針頭 ( LOT No 160612 )塑膠抽血針 具抽血，門診抽血病患共計11名患者陸續的口頭抱怨(約占使用此批號針具的抽血總人數的 五分之一)，主要抱怨都在門診抽完血離開檢驗室後，病患再回到檢驗室要求醫檢師更換浸 濕血液的止血棉球，當時抽血人員的初步懷疑病人的止血步驟不適當，但連續的病人發生 相同情形時，研判病患可能是血管傷口較大所造成的不適，立即檢討當時抽血的病人現況 與抽血人員的技術及病人是否有血液疾病等因素，再排除抽血技術與困難抽血及血液疾病 之因素後，最後懷疑是採血針頭的品質問題，經目視檢查採血針頭的外觀及用顯微鏡200倍 觀察針頭形狀，確認是採血”針頭變形”所導致，實驗室立即啟動耗材不良品的處置。因 此建議檢驗室必須建立一套確保採血針頭的安全流程，以提升採血品質及確保病人安全， 符合醫學檢驗室認證 ISO 15189 (5.3.2)：檢驗耗材在新使用批號或新進貨時，應在使用前加 以查證其性能之要求。作者建議檢驗室：(1)應採用知名品牌或高品質的抽血針具，(2)建立 採血針頭安全的檢視相關程序，並留有檢視紀錄及人員簽名，(3)抽血針具在新批號或新進 貨時，應隨機取樣目視檢查針頭，同時以顯微鏡100倍視野下觀察針頭是否異常，(4)教育抽 血人員，重視被抽血的抱怨反應及事件原因分析，尤其在病患多人的抱怨反映，(5)建立抽 血針具不良品的處理流程，應立即停用並與廠商聯絡處理，以提昇檢驗科的抽血品質及病 人安全。

Drawing blood is one of the works of medical technologist in the clinical pathology. The laboratory analyzes blood samples, and then provides the results for clinical screen, diagnostic, treatment and tracking. The medical technologists must ensure patient safety during the whole process of blood collection, after remove the collection needle, put on the sterile cotton on blood drawing area for stop bleeding. And educate the patient to straighten the arm, press the blood drawing area for 5 minutes until the blood stop bleeding. This is an uncommon case in the clinical; the poor-quality blood collection needle affecting patient safety when patient was drawing the blood. In 2016 Nov 20th to Nov 30th in our branch Tin-Chow lab, the medical technologists were using 5mL, gage 23 plastic blood collection needle (Lot number 160612) for phlebotomy, there were 11 patients one after another complain about pain after drawing the blood. (it's around 20 percent population complaints who was took blood by this lot needle.) And the patients come back to laboratory to request for another new sterile cotton for replacing the original cotton which is bloody. In the beginning, we doubt patient did not press well after drawing blood, but when it comes one after another, we suspect the cut is bigger and cause patients painful. We realized we should do the investigations, like root-cause analysis and fish-bone diagram, what cause patient so painful after drawing blood. it's about phlebotomist skill? Or patient who may has blood diseases? After we rule out these two reasons, we found the main reason is about needle quality, the needle isn't sharp enough for puncturing into the vein and it's cause the cut is bigger and bloody. We put needle under 100X microscope for observing the shape of the needle, the needle is out of shape, the shape isn't smooth. And then we report this adverse event to the hospital purchasing unit and request the supplier to do the investigation and corrections also. The laboratory must establish the procedure for choosing the safety syringes and needles, to protect healthcare workers from needlestick injuries and exposure to bloodborne pathogens, also provide the safe and comfort experience for patient. It also meets ISO 15189 5.3.2, ''Validate all pieces of equipment used for examination in the laboratory, including software systems. '' The author suggests the laboratory should develop the following steps for increasing the laboratory blood collection quality and patient safety: (1) purchasing the leading manufacture, which has high standard quality needle, (2) establish the purchasing and evaluation procedure, and leave the related checking records, documents and signatures, (3) randomly check the needles under the 100X microscope when the new shipment, lot. (4) to educate the phlebotomists periodically, especially pay attention patient complaints, when the adverse events happen often, do the root cause analysis when it is necessary. (5) to establish the procedure when the products do not meet the laboratory standard.