非計劃性氣管內管滑脫為常見之病人安全通報事項，一旦發生將影響病人安全，增加醫療耗費。透過現況分析，確立要因為鎮靜程度評估表（Richmond Agitation-Sedation Scale, RASS）認知不足、無RASS影音輔助教學內容、現行約束工具使用費時且難固定、跨團隊無共同平台討論呼吸訓練及拔管機制及RASS評估後分數沒有相對應的處置等。透過教育訓練、建構自拔高危因子篩選表、RASS評估警示機制、跨團隊介入及約束改良品等對策，使護理人員執行氣管內管照護正確率由68.5上升至96.3、約束技術正確率由68.5上升至96.3及RASS認知正確率由65.9上升至94.1，皆達專案目標。期間也未發生非計劃性氣管內管滑脫情形，顯示本專案措施介入確有其成效，共同維護病人安全，提升照護品質。

Unplanned endotracheal tube slippage is a frequent patient safety concern with significant implications for patient well-being and increased medical costs. A comprehensive analysis of the current situation revealed several fundamental causes, including inadequate awareness of the Richmond Agitation-Sedation Scale (RASS), a lack of multimedia computer-assisted instruction about RASS, inefficient and cumbersome restraint tools, the absence of a common platform for multidisciplinary discussion regarding respiratory training and extubation protocol, and a lack of corresponding management after RASS assessment. To address these critical issues and prevent future incidents, a series of preventive measures were implemented. These measures encompassed staff education and training, the creation of a risk-screening form for self-extubation, the implementation of a RASS warning system, multidisciplinary intervention, and advancements in restraint techniques. As a result of these proactive measures, the accuracy rate of nursing care in endotracheal tube and restraint techniques significantly increased from 68.5% to an impressive 96.3%. Additionally, the validity of RASS recognition rose from 65.9% to 94.1%, effectively reaching the project endpoints. Significantly, during the project period, there were no instances of unplanned endotracheal tube slippage, providing clear evidence of the effectiveness of these interventions. This project was successful and can be applied in clinical practice to uphold patient safety and enhance the overall quality of care.