透析過程若人工腎臟凝固，需中斷而影響透析品質。本專案目的在降低血液透析 人工腎臟凝固發生率。經分析原因：護理人員對預防人工腎臟凝固認知不足及預防人 工腎臟凝固作業流程不熟練、病人對水份控制差導致脫水量大於乾體重6% 及未做瘻 管自我照護、血液透析預防人工腎臟凝固作業流程不完整、缺乏定期考核技術及獎懲 制度。改善措施：安排在職教育、制定防凝五步口訣小語及安全標語海報、舉辦預防 人工腎臟凝固作業流程示教及練習、建立水份關懷登錄表、製作瘻管自我照護影片、 制定瘻管照護衛教指導單張、修訂血液透析預防人工腎臟凝固作業流程、訂定完整稽 核制度及獎勵辦法。專案結果：人工腎臟凝固發生率降至0.41%，能有效提升病人照 護品質。

If the artificial kidney is coagulated during the dialysis process, it needs to be interrupted to affect the quality of dialysis. Purpose of this project is reducing the incidence of hemodialysis artificial kidney coagulation. Reason for analysis: that nurse lack of awareness and sufficient familiarity with hemodialysis artificial kidney coagulation, failed to control the weight differences within the +6% of dry weight and have no self-care for vascular access of patient, incomplete procedures performed by nursing staffs, lack of evaluation and incentive system. Improvement measures included in this project: organizing of on-the-job training, develop five-step whispers and safety slogans, reverse education in technical procedures, elaborate water control form, produce vascular access self-care instruction leaflets and educational videos, revised standard hemodialysis protocols, and nursing guidance, set up nursing staff audit system with reward and punishments. Results of the project: the incidence of artificial kidney coagulation decreased to 0.41% improved thequality of nursing care.