背景 : 本單位自 2009年1月至 2009年6月，發生壓瘡有 8人，發生率佔 0.42%，與去年同期壓瘡發生率 0.28%比較，增加 0.14%，壓瘡發生率明顯上升。 目的 : 降低外科加護病房病人壓瘡發生率由 0.42%下降至 0.05%。 解決方案 : 實施介入措施中含括有：「舉辦預防壓瘡在職教育訓練」、「設定適當翻身工具，提供人員翻身使用、製作「正確翻身擺位姿勢參閱本」」，作為翻身擺位參考依據、「製作「病人皮膚完整性查檢表」，做為ㄧ致性交班工具」、「成立壓瘡照護品質稽核小組，作持續性監測」。 結果 : 壓瘡發生率由 0.42%降至 0.04%。 結論 : 顯示專案介入措施後能確實降低壓瘡發生率，提升照護品質。

Background: Pressure ulcers were an increasingly significant problem among patients in the authors’ ward. The eight patients diagnosed with pressure ulcers (0.42% of all inpatients) during the first half of 2009 represented a 140% increase over the first half of 2008 (0.28% of all inpatients). Purpose: This project was designed to reduce pressure ulcer incidence in the surgical intensive care unit (ICU) to 0.05%. Methods: Intervention measures included: 1) holding professional training on preventing pressure ulcers; 2) specifying appropriate patient turnover tools; 3) creating and distributing to nurses a proper turnover technique and positioning manual; 4) creating and distributing to nurses a comprehensive patient skin inspection checklist; and 5) organizing a permanent pressure ulcer care quality and audit committee. Results: Pressure ulcer incidence fell from 0.42% to 0.04% following implementation of the methods. Conclusion: Results demonstrate the effectiveness of using the proposed methods to reduce pressure ulcer incidence and enhance nursing care quality.