目的：依據衛生福利部訂定「提升管路安全」之安全目標，有效降低內科病房非計畫性鼻胃管自拔率，對提升管路安全具關鍵意義。材料與方法：分析2024年1-3月非計劃性鼻胃管自拔事件，主要原因：包括缺乏系統性培訓計畫暨手拍操作技能不足、預防拔管指導不完整、手拍功能不佳及未採購改良式手拍、以及無手拍操作步驟，據此（一）辦理手拍技能訓練及鼻胃管照護工作坊、（二）設置小心拔管牌、製作視覺衛教圖卡、制定操作步驟圖表、（三）汰舊更新並增購改良式手拍、（四）建立預防拔管與手拍使用的稽核及即時指導機制。結果：介入後，自拔率由0.19%降至0.07%，效果維持更降至0.04%以下，且重置率由57.1%降至0%。結論：透過結構化訓練與持續稽核，有效降低非計劃性鼻胃管自拔事件，促進病人安全及護理品質提升。

Objective: In line with the Ministry of Health and Welfare’s patient safety goal of “ enhancing tube safety,” this project aimed to effectively reduce the incidence of unplanned nasogastric (NG) tube self-removal in medical wards. Methods: Unplanned NG tube self-removal incidents from January to March 2024 were analyzed. The main causes identified included the lack of systematic training programs and insufficient hand restraint skills, incomplete education for tube removal prevention, poor performance of hand restraints with limited availability of improved devices, and the absence of standardized operational procedures. Based on these findings, the interventions included:,(1) conducting hand restraint skill training and NG tube care workshops; (2) placing caution signs, developing visual educational cards, and creating standardized procedure charts; (3) replacing old restraints and procuring improved models; and (4) establishing an audit and real-time coaching mechanism for tube removal prevention and hand restraint use. Results: After the intervention, the rate of unplanned NG tube self-removal decreased from 0.19% to 0.07%, with a sustained improvement further reducing the rate to below 0.04%. The tube reinsertion rate was also decreased from 57.1% to 0%. Conclusion: Through structured training and continual auditing, unplanned NG tube self-removal incidents can be reduced, thereby enhancing patient safety and improving nursing quality.