正確的手術器械清點，才能讓醫療安全及服務品質達到零風險。經現況分析發現：為配合手術室主管實施包盤減重政策及新增外傷骨專科醫師，異動骨科器械包盤給予重組及新增，進而發生12 件器械包盤清點異常事件，導致耗費人力協尋，直接影響手術進行造成工作不便。本專案目的：提升外傷骨科護理人員執行器械包盤清點正確性之改善，減少醫療錯誤的發生。藉由六項改善措施：修訂標準流程、編修器械參閱本、建置網際網路教學資料庫、舉辦教育訓練、製作器械清點教學光碟及建立器械清點作業監測機制。其結果顯示：護理人員執行外傷骨科器械包盤清點正確性由64.4％提升至100％達到本專案目的。透過專案的改善，不僅提升外傷骨科護理人員執行器械包盤清點之正確性，亦使器械遺失及遺留體內之錯誤達到零風險，提升病人手術安全。

The correct surgical instruments inventory can make medical treatment and service quality against any risk. Analysis of current situation found, for the sake of cooperating with the policy of operating room director to lighten instrument packages and to recruit more trauma orthopedic specialists, we reorganized and added more orthopedic instrument packages, which caused 12 times of failing to make an inventory, leading to the cost of manpower for looking for them, which directly affected the surgical operations and caused troubles. This project aims at enhancing the ability of trauma orthopedic nursing staff to carry out instrument packages inventory accurately, through six improvement measures to amend the standard of process, to compile instrument manuals, to built Internet teaching databases, to hold educational trainings, to make instruments inventory teaching disks and to establish the monitoring mechanism for the process of instruments inventory. The result shows: the rate of accuracy of nursing staff carrying out trauma orthopedic instrument packages inventory from 64.4% to 100%, which reach the goal of this project. The project not only improves the accuracy of trauma orthopedic nursing staff to carry out the instrument packages inventory, but also prevents from medical mistakes, which improves the safety of surgical operation.