本專案旨在降低豬尾巴引流管（pig-tail）及經皮穿肝膽道引流管（PTCD）的滑脫件數，經分析發現本院病房區引流管路滑脫件數高（共10件）。其所導致因素為：(1)固定方式不當。(2)引流管敷料使用不一致。(3)引流袋懸掛於身體兩旁，引流管傷口處無縫線支撐，病人易拉扯或坐到引流袋導致管路滑脫。(4)護理人員未測量引流管外露長度。(5)未重新修版pig-tail及PTCD引流管護理標準技術。經由實地觀察、現況分析和文獻查證，故教導引流管如何選用管路敷料固定方式，制定每日引流管護理追蹤紀錄單，設計引流管新式樣病人服供引流袋置放及修版此類引流管護理標準等解決方案，以改善引流管路滑脫的問題，進而將引流管滑脫件數降低為每年0件，藉此提昇護理照顧品質。

　　　　　The aim of the project was to reduce the slippage rate of pig-tail and percutaneous transhepatic cholangiolar drainage (PTCD) tubes. Ten events occurring in hospital wards were analyzed. The probable factors associated with drainage tubing slippage are as follows: (1) inappropriate methods of fixation, (2) inconsistent selection of covering materials, (3) not measuring the length of the outside portion of the drainage tube, (4) inadequate placement of drainage bag and no suture supporting the drainage wound opening, leading to the intertwining of lines and the patient inadvertently sitting on the bag, and (5) irregular evaluation of the drainage care technique performed by nursing staff. Through bedside observation, analysis of the current problems, and literature search, the appropriate selection of covering materials, the correct ways of fixation, daily critical evaluation of drainage tubing, revision of the standard procedures in care of the drainage tube, innovation in the design of the tubing and the placement of the drainage bag are recommended and should be promulgated to all nursing staff in order to reduce the rate of slippage and improve the quality of nursing care.