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檢視轉送時間表，並在個案離開單位前找出尚未解決的責任歸屬風險。

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Time	Data
1100	Hemoglobin is 8.4 g/dL after treatment. A repeat CBC is ordered for 1330 because the client had melena overnight.治療後血紅素為 8.4 g/dL。因個案夜間解黑便，醫囑於 1330 重複全血球計數。
1300	The transfer summary says 'repeat CBC pending,' but it does not name who will review the result or what change requires escalation.轉送摘要寫著「重複全血球計數待定」，但未指明誰將檢視結果，或什麼變化需要升級處理。
1315	The receiving nurse asks who owns the 1330 result. The sending nurse cannot identify an accountable clinician; transport is scheduled for 1320.接收單位護理師詢問誰負責 1330 的結果。送出單位護理師無法指出負責的臨床人員；運送排定於 1320。

Q1. What safety problem is revealed?揭露了什麼安全問題？

An accountability gap for a time-sensitive pending result有時效性的待定結果出現責任歸屬落差 An unnecessary delay caused by asking questions因提問造成不必要的延遲 A need to remove the pending result from the handoff需要從交班中移除待定結果

Q2. What should occur before transfer?轉送前應完成什麼？

Ask the family to look for the result請家屬留意結果 Transfer now and assume the facility will discover the order現在轉送，並假設機構會發現該醫囑 Name and confirm the result owner, review time, threshold, and escalation plan指名並確認結果負責人、檢視時間、閾值及升級計畫

Q3. Which statement best closes the loop?哪一項陳述最能完成閉環？

The result is in the chart if anyone wants it結果在病歷裡，任何人想要都可以看 You will review the 1330 CBC, call for the stated hemoglobin or bleeding threshold, and tell me now if you cannot accept that responsibility你將檢視 1330 的全血球計數，在達到所述血紅素或出血閾值時來電，若你無法接受該責任，現在就告訴我 Someone usually checks laboratory results after transport通常有人在運送後會檢查檢驗結果

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