手術室護理師執行器械計數之正確性及完整性影響手術病人的品質與安全；2018年3月至8月，手術室發生4件器械計數異常事件，有器械遺留病人體內之風險，故引發專案改善動機。調查發現器械計數異常原因有：護理師未依器械明細單計數器械、對器械計數認知不足、器械明細單未定期更新、器械明細單無圖解組裝零件數量、未定期舉辦相關在職教育、未確實稽核及器械計數作業規範不完整等，專案目的為提升手術室護理師執行器械計數之正確率，藉由修訂標準化手術器械計數流程、修編器械明細單、建立器械圖像資訊、定期舉辦器械計數教育課程及建立完整稽核制度，護理師執行器械計數認知由59.5%提升至100%，執行器械計數正確率由58.6%提升至100%，已達本專案目的。透過專案之改善結果發現，提升護理師執行器械計數之正確率，可以使器械遺留體內之風險降至最低，讓手術順利進行，更可提升病人手術安全。

From March 2018 to August 2018, there were 4 events of surgical instrument count errors that may increase the risk of retained surgical instrument. These errors motivated this project for improving the accuracy of surgical instrument count. Our investigation found that those errors came from an insufficient awareness of the surgical instrument count, such as not listing detailed parts of each instrument, not having an illustrated list, and not regularly holding in-service training. This project aimed to increase the accuracy of the surgical instrument count performed by operating room nurses by revising the standard process for counting surgical instruments, revising the instrument lists in the packages, establishing an image database of surgical instruments, holding in-service training for surgical instrument count on a regular basis, and developing an auditing system. After intervention, the awareness of instrument counts increased from 59.5% to 100.0% and the accuracy of instrument counts increased from 58.6% to 100.0%, meeting the goals of this project. Through this project, we can eliminate the risk of retained surgical instruments. By increasing the accuracy surgical instrument count, we ensure patient safety during operations.