病人接受血液透析過程因固定不完整，導致透析管路脫落情形時有所聞，本單位雖有管路照護規範但人員仍依過去個人舊有方式固定，且未按時檢視管路，亦缺乏管路安全在職教育，無提醒標語及護理記錄管路查核項目，致護理人員正確執行透析管路固定完整率為0％。本專案為提昇護理人員執行管路固定之完整率。採取五項措施：（1）修訂管路固定技術標準及增加護理記錄管路查核項目；（2）製作提醒小卡及管路固定輔助帶；（3）公告完整黏貼照片；（4）舉辦管路固定在職教育；（5）實施管路固定技術監測。實施後管路固定完整率由0％提昇至98.3％，各步驟正確率提昇至98.3％，期望改善措施能作為未來改善管路固定照護品質之參考。

During hemodialysis sessions, tube dislodgement due to incomplete tube fixation are commonly. Although our hemodialysis unit had defined regulations on tubing care, our nursing staff continued using their old methods of tube fixation. Tubing was not inspected regularly, no continuing education of tubing safety, no reminder notes and no checklist for tubing care in nursing records. These shortcomings led to an extraordinarily low completeness rate of 0% for tubing The goal of this project was to increase the completeness rate of tube fixation. We took five measures: (1) Amendment of standards of tube fixation techniques and adding checklist items to nursing records; (2) Design of reminder cards and tube fixing straps; (3) Posting of photos showing complete fixation; (4) Holding continuing education of tube fixation; (5) Monitoring techniques for tube fixation. After these measures were implemented, the completeness rate of tube fixation increased from 0% to 98.3%. Procedure compliance also increased to 98.3% We hope these measures can provide a reference for improving the care quality of tube fixation in the future.