背景:本單位2011年1月至6月，發生壓瘡件數共21件，發生密度為0.74%，高於2011年台灣臨床成效指標系統之醫學中心壓瘡發生密度0.62%，也高於去年本單位同期壓瘡發生密度0.55%。目的:降低兒童外科加護病房壓瘡發生密度由0.74%下降至0.31%。解決方案:本專案藉由舉辦在職教育、床邊教學、製作正確翻身擺位與管路固定之圖片、實施提醒機制、使用防壓輔具及成立稽核小組，以降低壓瘡發生密度。結果:2012年3月至7月壓瘡發生密度由0.74%降低至0.18%。結論　顯示實施改善方案後，能有效降低壓瘡發生密度，提升護理照護品質。

Background ＆ Problems: Our unit recorded 21 cases of pressure sores from January 2011 to June 2011. The resulting pressure-sore incidence density of 0.74% exceeded the Taiwan Clinical Performance Indicator (TCPI) for medical centers (0.62%) as well as the mean incidence density for our unit (0.55%) during the same period in 2010.Purpose: We developed this project to decrease the incidence density of pressure sores at our pediatric-surgical-intensive- care unit from 0.74% to 0.31%.Resolutions: Strategies implemented included: 1. providing on-the-job education; 2. providing bedside teaching; 3. developing a series of pictures to illustrate proper sitting, lying, and changing positions and the proper fixation of catheters; 4. implementing a reminder mechanism; 5. introducing pressure-preventing devices; 6. and establishing an audit team.Results: Incidence density decreased from 0.74% (Jan. to Jun. 2011) to 0.18% (Mar. to Jul. 2012). Conclusions: We demonstrated that the developed improvement program effectively reduced the incidence density of pressure sores and increased the quality of nursing care.