職業中接觸性血體液的流行病學分析及危害因素已是相當廣泛的研究議題，其中國內、外相關研究證實安全針具的推廣使用，可減低部分工作風險。國內也於2011年在醫療法令規範得推動安全針具的使用。然而，台灣線上針扎通報系統中得知安全針具的使用後，仍存在有針扎傷的潛在危害因素與相關問題。此外，通報內容設計的項目、選項資訊的明確、完整性，可能影響扎傷者填報意願、正確性。又扎傷者通報後，一般由感染管制、職業安全衛生管理人員進行事件調查、分析。因此本研究探討醫護人員在使用安全針具後的風險因素，並運用系統性的人因工程手法，了解根本原因，提出有效改善建議。
本研究主要分為二個部份，第一部份收集研究醫院通報資料分析之結果，了解針扎發生率的變化，是否因安全針具介入或危害因素未能被辨識而無法達到根本原因。第二部分安全針具針扎傷個案進行訪談作業，由訪談問項中導入人為失誤的模組，並按層推導可能失誤的因素至接近根本原因。在研究結果所呈現的風險因素具有，病人不配合、突如其來動作、工作倉促、混亂狀況,如急救、安全針具的使用不當,如安全機制的啟動未到位、操作未依規範、使用不熟悉、安全針具的針頭抽出仍然有外露空檔，誤認使用安全針具是安全、教育訓練不夠完整、監督、考核機制不足。
本研究期望藉由探討所得到的根本原因結果，提供醫院認知安全工程設計的注射工具，無法達到任何時候都是安全，必須按照步驟正確操作；並能參考規劃完整教育訓練與建立監督、考核機制，確認人員操作無誤再於臨床使用，以確保工作安全與健康。

The occupational blood issues like the epidemiological analysis and hazard factors are considerably widely studied; the effect of commonly using the safety needle on reducing some of the work risks is internationally confirmed and was domestically medically lawful in 2011.
Anyhow, in the Taiwan's online safety needle injury notification system after the effect, the hazard factors and associated issues remained potential. Additionally, the effect of the variables (clarity; completeness) affected the patient statement willingness and correctness. After the notification, the infection control and occupational safety and health management personnel generally investigated and analyzed the incidence. Therefore, this study (in: A human factors analysis on the risk factors of using safety engineered devices in a medical center) to understand the root causes proposed the effective improvement suggestions. The study was in:
1. the effect of analyzing the hospital's notification data on understanding whether that of the safety needle intervention or unrecognized hazard factors failed to reach the root causes.
2. the effect of interviewing the safety needle-injured on the root causes by deducing the probable errors. Accompanyingly, the risk factors were the patient incooperation: sudden patient movement; rushed injection; chaos like emergency; misused safetyneedle like the incompletely started safety mechanism; unregulated operation; misunderstanding and unfamiliarity-induced exposed needle; incomplete training and supervision and evaluation mechanism.
For work safety and health assuring, the effect of the root causes was on hospital instructing for safety needle using by the: accurate steps; complete training; supervision and evaluation mechanism for the correct clinical application.

第一章 緒論 1

第二章 文獻探討 10

第三章 研究方法 33

第四章 研究結果與討論 47

第五章 研究結論與建議 89

英文參考文獻 93
中文參考文獻 97
附錄 99

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