背景：2012年兒科加護單位非計畫性氣管內管滑脫，高於本院加護病房目標值0.28%。經專案改善小組，希望經由管路滑脫原因分析，歸納出管路滑脫事件之原因，包括：醫護人員未正確依氣管內管照護原則操作、醫療團隊對鎮靜處置未落實、照護認知不正確、未定期舉辦在職教育及照護安全評核等。目的：改善後非計畫性氣管內管滑脫率降至0.57%。解決方案設計及修訂氣管內管照護安全評核表、擬訂標準程序內容、修訂照護安全稽核，增購固定防水膠布、約束帶尺寸數量及製作鎮靜評估量表、教學光碟，提供照護安全教育訓練課程，以落實方案執行。結果：經計畫至執行後，評值改善策略之成效，非計畫性氣管內管滑脫改善後由0.76%降低至0.33%；護理師對於氣管內管照護安全完整性由27.2%提升至94.5%，改善成效顯著。結論：本專案建立氣管內管照護安全標準程序，可增進醫護照護團隊間溝通與合作，進而提升兒科管路照護安全及品質。

Background & Problems: In 2012, the rate of unexpected removal of endotracheal tubes in our pediatric intensive unit was above the maximum target level of 0.28%. We designed a survey to identify the relevant difficulties faced by nurses in order to formulate viable solutions and reduce the removal rate. After assessing the findings of this survey, we concluded that the following represented the primary difficulties: use of incorrect endotracheal tube care standards, the inadequate sedation of patients, the incorrect cognition of care of nurses, and lack of in-service education and securing techniques. Purposes: After implementing quality improvements to overcome these difficulties, the rate of unexpected removal dropped dramatically to 0.57%. Resolution: Our quality improvement strategy included: designing a protocol and a checklist for securing endotracheal tubes, purchasing additional waterproof tape and restraint straps, establishing a standard protocol for sedation, producing an educational DVD, and continuing in-service education. Results: After implementation of the above measures, the rate of unexpected removal fell dramatically from 0.76% to 0.33%. Additionally, the completion-of-care rate for patients with endotracheal tubes rose significantly from 27.2% to 94.5%. Conclusion: This project established a standard procedure for caring for endotracheal tube patients; improved communication among staff members; and reduced unexpected removal events.