非計劃性管路自拔為加護病房常見的醫療不良事件，一旦病人發生自拔管路的情形，常會導致嚴 重的合併症。經統計本單位2016年01月至2017年04月自拔發生率高達0.42%，由現況分析發現：醫護人員 缺乏評估病人delirium (譫妄)之認知能力與照護指引、護理人員未選擇合適的保護性約束工具、醫療圑隊 未儘早移除不必要的管路與未設有高危險群自拔病人提醒系統為主要原因。因此，本專案小組訂定的解 決策略包括：舉辦「加護病房譫妄病人臨床照護」教育課程、建立「加護病房病人譫妄照護指引」、建立 「保護性約束評估標準規範」、制定「ABCDE照護模式」、增加「高危險群自拔病人提醒系統」及定期稽 核。在專案推行三個月之後，非計劃性氣管内管自拔之發生率降至0.00%，初步達成此專案之目的，希望 藉由分享此專案，提供醫療人員能審慎評估病人的照護需求，降低病人管路自拔之風險。

Unplanned endotracheal extubation (UE) is a common adverse event in the intensive care unit (ICU),which causes serious complications. We collected data from January 2016 to April 2017 and found that the incidence of UE in our Medical Intensive Care Unit was 0.42%. The reasons of UE were lack of an assessment for diagnosing deliriums, practice physical restraint-protocol inappropriately, delayed extubation, and no alarm system for high risk of UE. We decided to promote the “ABCDE bundle” as our strategy to reduce the incidence of UE including holding an educational program, establishing a guideline for caring delirium patients in the ICU, practicing an assessment tool of physical restraint, and developing an alarm systems for high risk of UE. The project was executed from May 2017 to July 2017, and no UE was reported, the incidence of UE dropped to 0%. The results of this project may provide a model to reduce the incidence of UE in the ICU.