加護病房的病人疾病嚴重度高且管路複雜，一旦發生管路標示錯誤會導致病人嚴重傷害甚而影響生命安全。經調查加護病房護理人員執行管路標示正確性僅62.3%，主要問題為：1.交接班未一起檢視管路標示正確性；2.缺乏多媒體教學影像、無正確管路標示圖示；3.在職教育內容未提及管路標示方法、缺乏稽核制度等。專案小組共同擬定對策包括增設管路標示查核表、增加稽核制度、製作管路標示貼紙、製作管路標示標準化影片及QR Code、製作提醒小語及交接班管路人形圖、舉辦管路標示在職教育等。專案實施後，護理人員執行管路標示正確性由62.3%提升至100%，達到專案目的，顯示正確管路標示能避免臨床異常事件發生，亦能提升病人安全及臨床照護品質。

Patients in the Intensive Care Unit (ICU) have highly severe diseases and were inserted with complicated catheters. They’ll be confronted with serious injuries and even affected their safety of life once catheters are with wrong marked. After research, the nursing staff marked catheters with only 62.3% accuracy in ICU. The reasons were identified as followed: the handover without properly checking, lack of multimedia-teaching video and correct tags, in-service education without teaching the ways of tagging catheters, and lack of auditing system, etc. Our ad hoc group makes plans that included the establishment of a catheter marking checklist, setting up an auditing system, making the label stickers, teaching videos and QR codes, reminders and the nursing handover posters, organizing an in-service education about catheter tags. These implementations resulted in an improvement in the accuracy of marking catheters from 62.3% to 100%. In conclusion, the project had successfully achieved its original aim: correctly labeling marking not only can avoid unnatural events in clinical, but also can improve patients' safety and the quality of clinical nursing.