背景　長時間俯臥手術病人容易發生壓瘡併發症，造成病人疼痛及增加醫療成本。本單位長時間（4小時以上）俯臥手術病人臉部壓瘡的發生率為13.6%，經現況分析後發現其可控制的相關因素有：（1）脂肪頭圈不適用；（2）俯臥姿勢之標準作業流程未詳盡；（3）無臉部壓瘡追蹤制度。目的　4小時以上之俯臥手術病人臉部壓瘡發生率由13.6%降低至6.8%（50%降低率）。解決方案　（1）製作新型減壓輔助工具—水枕；（2）舉辦壓瘡預防及評估相關在職教育；（3）修定俯臥病人臉部評估及照護標準；（4）建立臉部壓瘡記錄單；（5）建立發生壓瘡病人之檢討及追蹤制度。結果　自2010年1月至10月間，俯臥4小時以上手術病人共116人，平均手術時間為4小時58分鐘，臉部壓瘡發生0人，臉部壓瘡發生率由原來13.6%降為0.0%。結論　使用水枕作為減壓輔助工具，同時針對護理同仁進行壓瘡之教育與評估追蹤制度，可有效改善長時間俯臥姿勢造成臉部壓瘡之發生。

Background & Problems: We observed in our institute a 13.6% incidence of prolonged surgery (>4 hours) induced facial pressure ulcers that required prone positioning. Causes identified included: (1) customized silicon face pillows used were not suited for every patient; (2) our institute lacked a standard operating procedure for prone positioning; (3) our institute lacked a postoperative evaluation and audit procedure for facial pressure ulcers.Purpose: We designed a strategy to reduce post-prolonged surgery facial pressure ulcer incidence requiring prone positioning by 50% (i.e., from 13.6% to 6.8%).Resolutions: We implemented the following: (1) Created a new water pillow to relieve facial pressure; (2) Implemented continuing education pressure ulcer prevention and evaluation; (3) Established protocols on standard care for prone-position patients and proper facial pressure ulcer identification; (4) Established a face pressure ulcers accident reporting mechanism; and (5) Established an audit mechanism facial pressure ulcer cases.Results: After implementing the resolution measures, 116 patients underwent prolonged surgery in a prone position (mean operating time: 298 mins). None suffered from facial pressure ulcers. The measures effectively reduced the incidence of facial pressure ulcers from 13.6% to 0.0%.Conclusions: The project used a water pillow to relieve facial pressure and educated staff to recognize and evaluate pressure ulcers. These measures were demonstrated effective in reducing the incidence of facial pressure ulcers caused by prolonged prone positioning.