由於本單位的入院後壓瘡率有逐月升高的情形，現況分析後發現護理人員執行翻身擺位的正確與否影響壓瘡的發生，經臨床監測護理人員的執行翻身擺位，正確率平均只達12%。進而探討導致翻身擺位執行不正確的因素有：(1) 護理標準欠完善；(2) 缺乏翻身擺位的教育訓練；(3) 未進行翻身擺位技術執行的控管；(4) 護理人員缺乏實際的演練，不熟練翻身擺位程序；(5) 翻身輔具不良；(6) 翻身輔具數量不足；(7) 防壓輔具使用不當；(8) 壓瘡發生率未列入單位之品管控制。經由文獻查證並與小組討論後，擬定下列措施進行改善：(一) 制訂詳細的翻身擺位程序標準技術；(二) 加強在職教育宣導、訓練；㈢增添翻身輔具枕頭與水枕；以及㈣檢討壓瘡率，進行案例分析。經由以上執行措施後，翻身擺位執行正確率由12%提升為88%，壓瘡率也由0.47%降低為0.05%，由此發現護理人員翻身擺位執行之正確率可能會影響壓瘡的發生率，因此期望藉由本專案提供給相關照護單位參考，共同提升病患之照護品質。

The incidence of pressure sores among inpatients had increased in our ward month by month. Clinical checklists and data analysis showed that the accuracy rate for nurses' changes of patients' positions was 12%. The investigation of reasons for this low accuracy rate included: (1) A flawed nursing standard for position changes. (2) Lack of training for position changing. (3) Lack of quality management and control of position changes. (4) Lack of practice and unfamiliarity with the procedures for position changing. (5) Poor quality of pressure-reducing surfaces. (6) Shortage of pressure-reducing surfaces. (7) Inappropriate method of use of pressure-reducing surfaces. (8) Non-inclusion by management of incidence of pressure sores within the scope of quality control. After a review of literature and group discussion, strategies were adopted to: (1) Establish a detailed explanation of standards for position changes. (2) Arrange lectures and promotional campaigns. (3) Add more pillows and water cushions. (4) Conduct case analysis when a patient develops a new pressure sore. After completion of this project, the accuracy rate for nurses' changes of patients' positions increased from 12% to 88%, and the incidence of pressure sores decreased from 0.47% to 0.05%. The result shows that accuracy of position change may affect the rate of pressure sore. We expect this project to serve as a reference in clinical practice for promotion of the quality of patient care.