| 關 鍵 詞： |
專案管理；外科系品質會議；非計畫重返手術室；相關及非相關手術；計畫及非計畫手術 |
| 中文摘要： |
非計畫重返手術室是台灣臨床成效指標手術照護中的重要指標之一，常與前次手術的併發症有高度的相關性，又不易釐清計畫與非計畫、相關與不相關，使這支指標的正確性備受爭議。團隊藉由專案管理手法達成 1. 指標統計一致與正確、2. 分析非計畫相關及非相關重返手術原因、3. 提升手術安全與照護品質。與 2014 年同期相比，2015 年嘉基非計畫性相關重返之發生率（P值）由 1.2％降低至 0.67％、2017 年 0.61％、2018 年 0.61％。藉由外科系品質會議逐案分析討論，整合醫療、護理、行政資訊共識，導正資料的正確性，由專案管理的過程重新檢視指標定義、指標收案流程及數值來源，可建立指標內部稽核制度及自我驗證指標資料正確性之機制，加強人員對醫療品質的重視度及參與度，讓病人安全與品質改善日常化。
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| 英文關鍵詞： |
project management；surgical quality conference；unplanned reoperation；related and unrelated surgery；planned and unplanned surgery |
| 英文摘要： |
Unplanned reoperation is a key indicator in surgical care category of Taiwan Clinical Performance Indicator and is highly correlated with complications associated with the previous operation. Distinguishing between planned and unplanned and related and unrelated surgery is difficult, and the correctness of indicators is frequently disputed. The research team used project management techniques (1) to obtain consistent and correct indicator statistics; (2) to analyze the reasons for unplanned reoperation; and (3) to improve surgical safety and care quality. Compared with 2014, in 2015, the incidence of unplanned reoperation (P value) in Ditmanson Medical Foundation Chia- Yi Christian Hospital decreased from 1.2% to 0.67% and further decreased to 0.61% in 2017 and 2018. Through the case-by-case analysis of cases presented at the surgical quality conference, the consensus on medical, nursing, and computer statistics was integrated to enhance data accuracy. Through reexamination of the definition of critical indicators, the process of indicator acceptance, and the source of values using project management techniques, an internal audit system for indicators and a mechanism for the self-verification of the correctness of indicator data was established to strengthen the attention and participation of medical personnel in medical quality, thereby improving medical quality and patient safety.
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| 目 次： |
前言
現況分析
實施方法
一、團隊成立
二、問題評估與原因分析
三、專案目的
四、介入措施
（一）重新釐定操作型定義
（二）2 次手術相關性與計畫性的釐清
（三）重整手術紀錄格式
（四）外科系品質會議
（五）修訂收案流程並至手術管理委員會溝通及宣導（圖2）
結果
討論
結論
參考文獻
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