壓瘡是長期臥床病人常見的問題，也是臨床護理照護品質重要指標。本專案在降低壓瘡發生率，以維護病人安全為目的，於2011年8月至2012年7月單位壓瘡發生率有逐月升高趨勢，且多為非壓瘡好發部位，經現況分析後發現主要為護理人員對壓瘡預防及翻身擺位教育訓練不足、無醫療輔具使用標準、翻身輔具不足及不良等因素。故擬定改善方案為舉辦在職教育、增設預防壓瘡措施及減壓輔具等方法。經介入方案後，前四個月發生率為0％，第五個月發生率5.9％，雖未達專案目標<3％，執行專案期間非壓瘡好發部位由3件降至1件，可見方案實施有顯著成效，因此期望此專案能提供給相關照護單位參考，以提昇護理照護品質。

Pressure ulcers are a common health problem among long-term bedridden patients and are regarded as an important indicator of quality of clinical nursing care. The purpose of this project was to ensure patient safety by reducing the incidence of pressure ulcers. The incidence of pressure ulcers in the study unit showed an upward trend month by month from August, 2011 to July, 2012, and most pressure ulcers occurred on uncommon areas. After analysis, the nursing problems were identified as follows: insufficient education and training of nurses in pressure ulcer prevention as well as turning and positioning, lack of standard operating procedures for medical assistive devices, and inadequate or defective turning assistive devices. The improvement strategies included providing in-service education, establishing pressure ulcer prevention guidelines, and adding pressure-relieving assistive devices. After the intervention, the incidence of pressure ulcers was 0% in the first four months and 5.9% in the fifth month. Although it did not reach the designated goal (< 3%), the number of uncommon areas where pressure ulcer occurred reduced from 3 to 1 during the project period, indicating a significant improvement after intervention. This project could serve as a reference for related care units in improving the quality of care.