經由手術過程所取得的病理組織在收集及運送的過程是一項極重要的工作，任何的出錯都將影響醫師的正確判讀、治療計畫及健保給付。本單位自2011年7月至9月病理組織送檢錯誤率為1.3%。同年9月並發生病理組織送檢錯誤重大事件，需送檢的病理組織因已完全切除，而無法重複取得，造成病人權益受損，且對本院醫療品質喪失信心，同時也造成日後醫療上的困擾。為找出造成錯誤原因，包括行政系統、執行步驟、軟硬體設備、工作人員等，首先利用病理檢驗科的退件登記表回溯資料，分析造成錯誤原因，再利用手術室查檢表，稽核工作人員實際作業狀況，分析可能造成錯誤原因，並實施相關改善辦法，使每月錯誤率能下降至0.2％，達到專案成立目標，藉此經驗分享能作為改善病理組織收集送檢參考依據。

The collection and transport of specimen obtained during surgical procedures is crucial. Error in the procedures can affect doctor’s decision on patient’s treatment plan and national health insurance reimbursement. From July to September, 2011, there were 1.3% error rate on delivering pathological specimen. In the same period, a severe error in specimen delivery was committed in September in our hospital division. Because the pathological specimen had been completely removed from the patients’ body, no more specimens could be obtained. This incident gravely undermined the patient’s rights, and induced patient’s loss of confidence in the quality of medical care provided by our hospital. Moreover, this error hindered future medical treatment. The objective of this study was to determine the reasons for this error; thus, the administration system, implementation processes, software and hardware, and hospital staff were investigated. To analyze the possible causes of the incident, we first reviewed the pathology department’s specimen rejection records to trace back the relevant data. Second, we reviewed the operating room checklists to investigate the actual clinical practices employed by the staff. Subsequently, we implemented improvement measures that reduced the rate of error to 0.2%, in accordance with the objectives of the present study. This paper serves as reference for improving the biopsy collection and transport process.