透析管路異常發生不僅會造成病人血液流失，使得病情加重需延長住院天數，甚至引起病患死亡或醫療糾紛發生。本專案主旨在降低血液透析管路異常事件發生率。統計2016 年7 至12 月發生率為2.43‰，為探究原因成立專案小組，經查核發現未確實執行透析技術、預防血液透析管路異常認知不足、未建立稽核制度、缺乏管路安全在職教育、單位缺乏提醒標語、缺乏管路固定之輔助工具。經修修訂「血液透析治療技術標準」、培訓種子教師、定期執行血液透析技術稽核、舉辦管路安全在職教育、製作異常提醒標語旋轉盤、創新製作手臂固定板等進行5 個月對策實施後，降低透析管路異常事件發生率由2.43‰ 至0.42‰，本專案不僅提升降低透析管路異常發生，更加強病人對透析管路自我照護知識。

Tubing complications not only cause blood loss, but also increase the length of hospitalisation for patients. In some cases, they may even lead to patient death and medical disputes. Against such a backdrop, this project was launched with the aim of reducing the incidence of haemodialysis tubing complications. From July to December of 2016, said incidence rate was 2.43‰, and a project team was formed to investigate the reasons behind the incidents that occurred. It was discovered that the causes included inadequate execution of haemodialysis techniques; the lack of knowledge regarding the prevention of haemodialysis tubing complications; the absence of an audit system; the lack of in-service education covering tubing safety; the lack of reminder slogans within the unit; and the lack of auxiliary tools for securing tubing. The following response measures were implemented over a five-month period: the revision of the hospital’s Technical Standards for Haemodialysis Treatments; the training of seed teachers who can provide instruction on the use of haemodialysis machines; the implementation of regular audits for haemodialysis technique; the provision of in-service education covering tubing safety; the creation of display stands for reminder slogans; and the development of an arm board for securement purposes. These measures reduced the incidence of haemodialysis tubing complications from 2.43‰ to 0.42‰, indicating that the project had not just achieved its primary aim, but also enhanced the selfcare knowledge of patients with respect to dialysis tubing.