在二十世紀末全球醫學的進步已經接近人類健康照護的夢想，但潛藏醫療流程面的研究卻無法並駕齊驅。1999年｢人就是會犯錯｣(To Err is Human)報告一棒敲醒沉醉在自滿中的醫療界，經過四年向企業界與軍事領域的學習與檢討後，在2003年提出｢以病人安全為中心｣的呼籲，其中交班溝通問題一直是造成病人安全警訊事件的最大根本原因。在醫療科技日益分工之際，病人輾轉在各種專家與部門之間接受檢查、診斷、治療與復健，交班更是臨床上例行且重要的工作。雖然一直列入改善病人安全目標，但在醫學界如何向企業界學習交班流程改善的研究卻是寥寥無幾。
許多研究顯示｢經營流程管理｣(Business Process Management)能協助企業持續改善流程以保有高度的競爭力，流程改善與人的參與是經營流程管理的兩大核心精神。本研究探討經由團隊資源運作與模擬演練介入的經營流程管理對於交班模式的影響力；並設計問卷對於改善前後之維護病人安全、交班正確完整性與交班效率三部份進行資料收集。本研究期待引用此手法，先探討交班現況的問題，最後建立出最佳交班流程。以檢討這兩種介入措施後改善交班模式的幅度。
本研究於引進團隊資源運作與模擬演練的過程中，逐步改善流程設計與增進團隊人員的參與感，有效落實經營流程管理於交班模式中。藉由本研究所發展之交班有效性改善模式，快速建立個案醫院之最佳交班模式，大幅改善交班正確完整性與交班效率，以維護病人安全。經統計分析，發現在交班過程會影響病人安全時，藉由經營流程管理的手法確能改善交班模式的有效性。

In the twentieth century global medical progress is close to human health care dream, but the studies focusing on lurk medical processes are unable to work in parallel plane. In 1999, the IOM report about “to err is human” sounds the alarm for those medical professionals who immerse themselves in complacency. After 4 years benchmarking studies and reviews to the business world and the military field, in 2004 WHO urged all WHO states to pay the closes possible attention to the problems of patient safety. Through the studies of sentinel events resulting in patient harm, the communication breakdowns was the main root cause. On the occasion of the growing division of medical technology, the patient who was transferred among a variety of experts and authorities to accept checks, diagnosis, treatment and rehabilitation, handovers between experts is one of the clinically routine and important efforts. Although there have been included to improve patient safety goals, but in the medical sector studies about handovers to enhance the communication process is sparse.
Many studies show that “business process management” could assist enterprises continued to make better processes to retain a high degree of competitiveness. Process improvement and people's participation are the two central cores in business process management. So, we tried to employ TeamSTEPPS and simulation walkthrough business process management for perking up the medical handovers. We collected the data using questionnaire for the measurement of improving the patient safety, the shift in the correct integrity and efficiency of handover. This study looks forward to measure the improvement and to establish the best handover process through the both intervention.
This study was to introduce TeamSTEPPS and simulation that swiftly but surely improve medical process and augment the sense of team involvement, effective implementation of the business process management to handover mode. Through this study of development effectiveness improvement mode, change for the better handover was rapidly established in hospital, substantially improve the integrity and the efficiency of patient safety. With the launch of the business process management can improve the effectiveness of the handover mode in health care.

參考資料
中文部份
行政院衛生署 (2008). 醫療品質及病人安全年度工作目標建議參考作法手冊. 財團法人醫院評鑑暨醫療品質策進會.
呂俊德;黃郁琮;陳秀貲 (2007). ARIS流程管理方法在醫療作業流程之應用：以某區域醫院為例. 醫務管理期刊, 8(2), 172-193.
周碧琴、王麗玲、施靜宜、彭郁茹、林玉梅、李麗琴、趙倩、李碧雲 (1997). 護理人員交班方式改善方案. 長庚護理, 8(2), 81-89.
張嘉娟、江靜怡、黃錦鳳、江健婷 (1998). 交班改善方案之成效探討. 長庚護理, 9(3), 50-59.
陳秀蓮、林玉如、賴瑞婷、黃家萍、黃春戀、郭婷婷 (2002). 急診病患轉送病房護理交班之改善方案. 醫務管理期刊, 3(3), 104-117.

英文部份
Aiken, L. H. (2006). Nursing Research: Methods and Critical Appraisal for Evidence-Based Practice: Mosby.
Benson, E., Rippin-Sisler, C., Kimberfyjabusch, & Keast, S. (2007). Improving Nursing Shift-to-Shift Report. Journal Nursing Care Quality, 22(1), 80-84.
Berkenstadt, H. (2008). Improving handoff communications in critical care: utilization simulation-based training toward process improvement in managing patient risks. Chest, 134, 158-162.
Bosilj-Vuksic, V., Stemberger, M. I., Jaklic, J., & Kovacic, A. (2002). Assessment of e-business transformation using simulation modeling. Simulation, 78(12), 731-744.
Brennan, T. A. L., Lucian L.; Laird, Nan M., et al. (1991). Incidence of adverse events and negligence in hospitalized patients: Results of the Harvard Medical Practice Study I. New England Journal of Medicine, 324, 370-376.
Carpinetti, L. (2003). Quality management and improvement: a framework and a business–process reference model. Business Process Management Journal, 9(4), 543-554.
Catchpole, K., Giddings, A., & Leval, M. d. (2006). Identification of systems failures in successful paediatric cardiac surgery. Ergonomics, 49, 567-588.
Catchpole, K., Leval, M. D., & McEwan, A. (2007). Patient handover from surgery to intensive care: using formula 1 pit-stop and aviation models to improve safety and quality. Pediatric Anaesthesiology, 17, 470-478.
Davenport, T. H. (1993). Need radical innovation and continuous improvement? Integrate process reengineering and TQM. Planning Review, 21(3), 6-12.
Davenport, T. H., & Short, J. E. (1990). The new industrial engineering: information technology and business process redesign. Sloan Management Review(Summer), 11-27.
Davies, J. M., & Helmreich, R. L. (1996). Simulation: it’s a start. . Can Anaesth Soc J, 43, 425-429.
Defontes, J., & Surbida, S. (2004). Preoperative safety briefing project. The Permanente Journal, 8, 21-27.
Derossis AM, B. J., Sigman HH, Fried GM (1998). The effect of paroctice on performance in a laparoscopic simulator. Surg Endoscopy, 12, 1117-1120.
Dusterberry, J. (1975). Introduction to simulation systems. Society of Photo-optical Engineers, 59, 141-142.
Elzinga, J. (1995). Business process management: survey and methodology. IEEE Transactions on Engineering Management, 42(2), 119-128.
Ericsson, A. K. (1996). The Road to Excellence: The Acquisition of Expert Performance in the Arts and Sciences, Sports, and Games: Lawrence Erlbaum Assoc Inc.
Gaba DM, H. S., Flanagan B, Smith BE, Fish KJ, Botney R. (1998). Assessment of clinical performance during simulated crisis using both technical and behavorial ratings. . Anesthesiology, 89, 8-18.
Gordon MS, E. G., Eflner JM (1980). Teachin Bedside cardiologic examination skills using "Harvey" the cardiology simulator. Med Clin North Am, 64, 305-313.
Grogan EL, S. R., France DJ, et al. (2004). The impact of aviation-based teamwork training on the attitudes of healthcare professionals. . J Am Coll Surg. , 199, 843-848.
Grogan, E. L., Stiles, R. A., & France, D. J. (2004). The impact of aviation-based teamwork training on the attitudes of healthcare professionals. . J Am Coll Surg. , 199, 843-848.
Hammer, M. (1990). Reengineering work: don't automate, obliterate. Harvard Business Review, 68(4), 104-112.
Hammer, M. (1996). Beyond Reengineering: How the Process-Centered Organization is Changing Our Work and Our Lives: New York: Harper Collins.
Hammer, M., & Champy, J. (1993). Reengineering the Corporation: A Manifesto for Business Revolution: New York: Harper Business.
Hung, R. Y.-Y. (2006). Business Process Management as Competitive Advantage: a Review and Empirical Study. Total Quality Manangement, 17(1), 21-40.
JCAHO (2007). Improving America's hospitals: the Joint Commission's annual report on quality and safety, 2007, from http://www.jointcommissionreport.org/pdf/JC_2007_Annual_Report.pdf
JCAHO (2009). 2009 National Patient Safety Goals Implementation Expectations 2008., from http://www.jointcommission.org/accredited+organizations/patient+safety/09_nssg_ie.pdf
Kaneko M, P. N., Copeland JG (1988). A simple, working heart and lung transplant model for assessing preservation methods in the rabbit. Transplantation, 46(4), 624-626.
Kilmann, R. (1995). A holistic program and critical success factors of corporate transformation. European Management Journal, 13(2), 175-186.
Kohn, L. T., Corrigan, J. M., & Donaldson, M. S. (1999). To Err Is Human: Building a Safer Health System: Committee on Quality of Health Care in America, Institute of Medicine.
Lauber JK, O. H., Foushee HC Cockpit resource management: background and overview. Cockpit resource management training: proceedings of the NASA/MAC workshop. Moffett Field, Calif: NASA-Ames Research Center. NASA Conference Publication, 2455.
LK, K. (2002). The new paradigm of crew resource management: just what is needed to reengage the stalled collaborative movement. J Qual Improv., 28, 235-241.
Malloch, K., Moore, N., & D.Sluyter (2000). Relationship centered care: achieving true value in healthcare. . J Nurs Adm., 30, 379-385.
Mosher, C., & Bontomasi, R. (2006). How to Improve Your Shift Report The American Journal of Nursing 96(8), 32-34.
Nieva, V., & Sorra, J. (2003). Safety culture assessment: a tool for improving patient safety in healthcare organizations. Quality Safety Health Care, 12(Suppl 2:ii), 17-23.
Pizzi L, G. N., Nash DB. (2001). Crew resource management and its application in medicine. Rockville Agency for Healthcare Research and Quality.
Pritchard, J. P., & Armistead, C. (1999). Business process management - lessons from European business. Business Process Management Journal, 5(1), 10-35.
Pronovost, P., & Weast, B. (2005). Implementing and validating a comprehensive unit-based safety program. Journal Patient Safety, 1, 33-40.
Reiley, P., & Stengrevice, S. (1988). Change-of-shift report put it in writing. Nursing Managemen t, 20(9), 54-56.
Rosemann, M., Alonso, G., & Dadam, P. (2007). Business process management : 5th international conference, BPM 2007, Brisbane, Australia, September 24-28, 2007 : proceedings. Berlin ; New York: Springer.
S. Barry Issenberg. (1999). Simulation Technology for Health Care Professional Skills Training and Assessment. JAMA, 282(9), 861-866.
Schniederjans, M., & Kim, G. (2003). Implementing enterprise resource planning systems with total quality control and business process reengineering. Int. J. Oper. Prod. Manag., 23, 418-429.
Smith, H., & Fingar, P. (2007). Business process management : the third wave ([4th Anniversary ed.). Tampa, Fla.: Meghan-Kiffer Press.
The Flight Management Attitudes Questionnaire (FMAQ)(1993).
Vincent, C. (2007). from http://www.utpatientsafety.org
Vincent, C., Taylor-Adams, S., & Stanhope, N. (1998). Framework for analyzing risk and safety in clinical medicine. British Medical Journal, 316, 1154-1157.
Waugh RA, M. J., Ewy GA (1995). Multimedia computer-assisted insturction in cardiology. Arch Intern Med, 155, 197-203.
Weller J, W. L., Robinson B. (2003). Survey of change in proctice following simulation-based training in crisis management. Anaesthesia, 58, 471-479.
Wiener, E. L., Kanki, B. G., & Helmreich, R. L. (1993). Cockpit resource management. . San Diego, Calif: Academic Press, Inc.
Williams, A. J. (1998). Managing change in the nursing handover. Nursing Standard, 12(18), 39-42.
Zairi, M. (1997). Business process management: a boundaryless approach to modern competitiveness. Business Process Management Journal, 3(1), 64-75.
Zairi, M., & Sinclair, D. (1995). BPR and process management: a survey of current practice and future trends in integrated management. Business Process Re-engineering and Management Journal, 1(1), 8-29.
ZinnC. (1995). 14,000 preventable deaths in Australia. British Medical Journal, 310(1487).