自傷行為是精神科病房常見之病人安全問題，本文針對2009年9月出現自傷行為之某案例，進行根本原因分析，並依根本原因設計與執行改善方案，並作執行成果之評值，期待降低精神科住院病人自傷率由0.12%降至0.09%以下。自2009年10月1日至2010年10月31日，小組成員規範護理師巡房及當病人情緒不穩之處置常規：主動關切及提供陪伴、執行立即之危險物品安全檢查、制訂危險物品安全檢查作業規範，包括：結構性安檢查檢表及明訂安檢時機等，並提供家屬陪伴責任及注意事項之衛教單張。自傷率可從2009年1至9月平均之0.12%下降至2010年1至10月平均之0.08%;另外執行結構性危險物品安檢查檢率可從82.8%提升至99.8%;而2011到2013年分別平均為99.2%、99.5%及99.6%。本專案之自傷率可逐步下降，以提升及落實病人安全之作法，呈現出更具體之醫護照顧成效。

Self-harm behavior is a common safety issue for patients in the psychiatric ward. This article demonstrated a case with self-harm behavior in September 2009. Applying root cause analysis and implementation of an improvement plan in accordance with the underlying cause are expected to reduce psychiatric inpatients self-injury rate from 0.12% to less than 0.09%. From October 1, 2009 to October 31, 2010, members of the group established standard procedures for nurse ward rounds. Conventional disposal such as active care and companionship, safety inspection of dangerous goods according to standard protocol including structural safety inspection checklist are provided immediately while mood swings is noted in patients. Family accompany responsibility is requested and precaution education leaflets is provided. The average rate of selfharm behavior was dropped from 0.12% to 0.08%, comparing two durations between from January 2009 to September 2009 and from January 2011 to October 2011. The implementation of structural safety checklist of dangerous goods increased from 82.8% to 99.8%. From 2011 to 2013, the average rate of checklist implementation rate was 99.2%, 99.5% and 99.6%, respectively. By implementation of safety practice as this project, the self-harm rate may gradually decline and provide a more effective care.