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某單位發現最近 600 次採集中有 7 次未標示的檢體送達實驗室。領導者希望明天強制推行全院性的工作流程變更。完成績效改善陳述。

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The team should first ::선택::identify the staff member involved in the most recent eventstop collecting incident reports until the workflow changesannounce that the intervention has already succeededdefine a measurable aim and establish the baseline process and outcome data, then ::선택::test the defined change on one unit through a small PDSA cyclerequire every hospital unit to change simultaneouslywait until an unlabeled specimen causes permanent harmreplace measurement with informal staff impressions, and before broader spread ::선택::use only one post-change data pointremove balancing measures that could slow adoptionstudy run-chart, process, outcome, and balancing data and adapt the next cycleassume that no new report means the problem is solved.

團隊應先 ::선택::辨識最近一次事件中涉及的員工停止收集事件報告直到工作流程變更宣布介入措施已經成功定義可量測的目標並建立基線過程與結果數據，然後 ::선택::透過小規模 PDSA 循環在一個單位測試所定義的變更要求每個醫院單位同時變更等到未標示的檢體造成永久性傷害以非正式員工印象取代量測，並在廣泛推廣前 ::선택::僅使用單一變更後數據點移除可能減緩採用的平衡量測研究趨勢圖、過程、結果與平衡數據並調整下一個循環假設沒有新報告代表問題已解決。

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