氣管內管留置爲重症病人常見處置，一旦發生非計畫性滑脫，不僅增加醫療資源耗用，更可能危害病人安全。本專案旨在降低重症病人非計畫性氣管內管滑脫發生率。統計本單位2008年7月至12月中旬間之非計畫性氣管內管滑脫率爲0.65%。經參與品質突破系列模式並以跨團隊方式進行改善對策，包含制定氣管內管照護安全考核表、稽核物理性約束正確性、建立鎮靜止痛標準作業流程、擬定高危險病人篩選表、創意設計保命防拔標籤、安排會說病人慣用語之人員進行照護，及推展氣管內管照護教育課程，並提供衛教資訊、鼓勵病家參與病人安全工作等解決方案。執行解決方案9個月後，病人之非計畫性氣管內管滑脫率已降至0.22%。醫療院所可參考本專案之成效進一步擬定適合各醫院的策略及方針，降低非計畫性管路滑脫事件，以共同提升醫療照護品質。

Insertion of endotracheal tubes (ETTs) was the common procedure in critical care units. Once ETT dislodged unexpectedly, it may not only increase the medical expense but also endanger the patients' safety. Our current project aim to reduce the incidence rate of ETT dislodgement by utilizing Breakthough Series (BTS) Model. This model consisted of seven items, including (1) a checklist for ETT fixation procedures, (2) a checklist for standard physical constraints, (3) a standard protocal for sedation and analgesia, (4) identification of high-risk patients of dislodgement, (5) a reminder card at bedside, (6) primary care nursing who can speak patients' mother language, and (7) continuous medical education about ETT care. After implementation of this model for 9 months, the incidence rate of ETT dislodgement dramatically dropped from 0.65% in 2008 to 0.22% in 2009. Our succeful experiences demonstrated that BTS Model can be generally applied to other units who were also making efforts to reduce unexpected tube dislodgement and to promote healthcare quality.