非計劃拔管事件嚴重危害病人的安全，也是重要的醫療品質議題。本專案旨在降低新生兒加護病房非計劃性氣管內管拔除率。現況調查發現：新生兒躁動扭動頭部、唾液過多降低膠帶黏性易鬆脫、醫療人員協助新生兒擺位不當、呼吸器管路無法確實被固定支撐，以及氣管內管照護標準不一致為導致因素。經文獻查證與討論後，提出解決辦法：（一）舉辦醫療照護人員氣管內管留置照護教育訓練；（二） 增修「氣管內管留置新生兒照護標準」，增加圖示說明、修正趴睡時的擺位姿勢、防水型管路固定用膠帶使用及呼吸管路支撐點；（三）製定階段性獎勵政策；（四）擬訂稽核計畫並執行。經改善方案實施後，非計劃性氣管內管拔除率由改善前0.65%降至0.19%，以及護理人員執行氣管內管照護正確率由改善前67%提升至94.3%。顯示本專案之改善方案確實能有效達成改善的目的，期望藉此專案之成效能維護新生兒安全、提升照護品質。

Unplanned extubation (UPE) events cause a serious hazard to patient safety and are reflective of patient care quality issue. The aim of this project was to reduce the UPE rate in the NICU. Factors leading to UPE included head rolling when agitated, adhesive tape loosened by copious secretions, malpositioning by healthcare provider, unsupported ventilation tubing, and incomprehensive care. The implemented interventions were as follows: (1) provided continuing education courses regarding endotracheal tube care; (2) revised the policy for “standard care for endotrachea tube” with new pictorial description, modified prone sleep positioning, endotracheal tube stabilization by using water resistant tape, and ventilator circuit fixation; (3) developed a team reward system; and (4) developed a quality monitoring program after implementation of above interventions. After implementation of this program, the UPE rate decreased from 0.65% to 0.19% and rate of appropriate endotracheal care was increased from 67% to 94.3%, which met our goal. Through this project, health care workers are able to provide better quality of care and prevent inadvertent extubation.