交班是重要的護理專業實務，而交班完整可提高病人安全、降低人員間衝突，達到持續性照護之目標。2016 年9 月12 日至18 日小組稽核發現，護理人員單位內交班遺漏達38.29%，主要原因為對交班內容認知不同、缺乏交班制度、個人小抄交班單未統一及護理交班單不符實際需求等問題。為達降至10 %的目標值，藉由建立交班共識項目、製作交班指引單、制定呼吸照護病房專用交班原則、制定交班順序清單、統一單位個人交班單、修訂Kardex 交班單及Kardex 交班單顏色化等改善方案後，單位內交班遺漏率降至4.46%。專案運用ISBAR 模式與交班項目結合，讓交班認知一致，進而降低交班遺漏率，獲得護理人員的正向肯定，達專案改善目的。

The nurse-to-nurse handover is an important practice of nursing, Completion of the handover can improve the patient's safety, reduce the conflict between staffs and reach the goal of continuous care. From September 12th to 18th, 2016, we found that the omission rate of the hand-off report was 38.29%. The main causes of this were different cognition on the contents of the handover, lack of handover system, the un-unified personal cheat sheet, and the kardex not conforming to the actual demand. For reaching the goal of 10%. After setting up a consensus project, creating the shift guideline, formulating the special shift principle for the respiratory care ward, making order list of the shifts, unifying the individual shift orders, revising the kardex, and color-coding the kardex, the omission rate had dropped from 38.29% to 4.46%. This project used the ISBAR mode and integrated the handover items to make the handover cognition to be consistent, then reduced the handover omission rate and obtained the nursing staff's positive affirmation. The goals of the project were achieved.