血液腫瘤病人因疾病或治療，導致免疫低下感染風險，治療採抗生素合併使用，本單位2020年1-6月抗藥菌感染平均發生密度達4.39‰，現況分析護理師隔離防護措施完成率、手部衛生執行率及正確率，分別達75.7%、49.1%及54.5%。主要問題：護理師認知不足、未落實洗手五時機及隔離防護措施、未例行舉辦抗藥菌教育訓練或團體衛教、隔離標示無濕洗手、病人／家屬不認識隔離標示。改善措施：製作濕洗手標示卡、舉辦教育訓練、修訂指導單張及海報、口訣，結合隨選衛教系統，有效降低抗藥菌感染發生密度3.69‰，護理師隔離防護措施完成率、手部衛生執行率及正確率，分別提升至95.2%、80.9%及 82.7%，也具顯著成效。

Hematology patients receive antibiotics because of the disease and chemotherapy related immunocompromised status. In our units, the average density of multidrug-resistant infection is 4.39‰ from January to June in 2020. We observed and analyzed the completion rate of isolation precaution, the timing and accuracy of hand hygiene of nurses. The rates are 75.7%, 49.1% and 54.5%, respectively. The major problems were: lack of knowledge about isolation precaution, nurses do not truly implement the timing and steps of hand hygiene and isolation precaution, educational or group training program about drug resistant bacteria are not routinely provided, lack of sign for soap and water handwashing and patient or family don’t recognize the sign of isolation. Our interventions were creating the card of soap and water handwashing, hosting education and training, revising patient education instruction or posters, creating slogan phrase for isolation precaution and integrating with E-nursing system. After the implantations, the average density of multidrug-resistant infection decreased to 3.69‰; the completion rate of isolation precaution, the timing and accuracy of hand hygiene improved to 95.2%, 80.9% and 82.7%, respectively.