目的 本專案旨在降低暫時性血液透析導管滑脫率。單位2018年1至3月滑脫率高達0.12％，接連的管路異常事件，除了病人需面臨再次植入導管的痛苦，也引發家屬及醫療團隊質疑護理的專業性，故成立專案小組。
方法 利用異常事件回溯資料分析、實際查核及人員訪談，確立問題一、人員：管路安全敏感性不足、約束不正確、未提供衛教；二、設備：管路固定不牢、約束工具不足；三、制度：缺乏稽核制度及照護查核指引。進行改善措施：包括一、增設管路提醒圖卡；二、舉辦在職教育；三、制作管路固定模具及固定教學影音檔；四、改變敷料加強固定；五、提供照護查核指引；六、稽核及獎懲回饋機制。
結果 暫時性血液透析導管滑脫率由0.12％降為0％；暫時性血液透析導管照護正確率皆達100％，成效甚佳。
結論 藉由暫時性血液透析導管照護標準的建立，落實暫時性血液透析導管評估及留置照護，可提升病人管路安全。

Purposes This study aimed to reduce the slippage rate of temporary hemodialysis catheters. From January to March 2018, the slippage rate in our institution was as high as 0.12%. Successive abnormal tubing events not only cause patients pain caused by catheter re-implantation, they make family members and the medical team question nursing professionalism.
Methods Through a retrospective data analysis, an on-site inspection, and personnel interviews about abnormal events, the following problems were identified: (1) Personnel: insufficient sensitivity about tubing safety, incorrect binding, and inadequate health education; (2) Devices: tubing inadequately fixed and insufficient binding tools; and (3) System: lack of an auditing system and nursing inspection guidelines. The improvement measures included: (1) adding tubing reminder picture cards; (2) organizing on-the-job education; (3) creating tubing fixation molds and fixation instruction audiovisual files; (4) changing dressings to reinforce the fixation; (5) providing guidelines for nursing inspection; and (6) performing audits and creating reward and punishment feedback mechanisms.
Results The slippage rate of temporary hemodialysis catheters decreased from 0.12% to 0%. The temporary hemodialysis catheter success rate was 100%, and its effect was very satisfactory.
Conclusions Patients’ tubing safety can be improved through the establishment of temporary hemodialysis catheter care standards as well as the implementation of temporary hemodialysis catheter evaluations and indwelling care protocols.