背景 : 不當的手術擺位會導致病人無效的呼吸型態、氣體交換不足、組織灌流失常與皮膚完整性受損等。之前單位曾發生擺位設備於手術中鬆脫，造成身體移位，導致手術區染污的情形，基於維護手術中病人安全，引發專案改善動機。 目的 : 提昇手術室護理人員執行手術擺位安全照護正確性、提昇護理人員的專業知能、保障手術病人的安全，以避免不必要傷害發生。 解決方案 : 舉辦教育訓練、建立擺位安全照護作業標準化、制定擺位安全照護查檢表、擺位配件檢視及增設活動式約束帶、定期稽核機制。 結果 : 執行正確性由 80%提升至 100%；知識由 88%提升至 100%。 結論 : 提供良好的手術擺位設備以保護病人，讓手術病人能得到最完善、最安全的手術。建議將相關手術擺位安全照護訓練列入定期教育課程，強化人員對手術擺位安全照護作業知識有其必要性。

Backgrounds: Inappropriate patient positioning during surgery causes respiratory pattern changes, inadequate gaseous exchange, tissue hypoperfusion and disruption of skin integrity. Inadvertent loosening of positioning devices on a patient in our ward during surgery caused surgical field contamination. We thus proposed a project to promote patient positioning accuracy in operating rooms to improve patient safety. Purposes: This project was intended to promote accurate patient positioning by operating room nurses, raise nursing professionalism, ensure patient safety, and avoid unnecessary patient injury. Resolutions: Under the project, we held educational training programs, developed patient positioning standard operating procedures (SOPs) and check lists, inspected all positioning assistance devices, purchased additional belt restraint straps, and conducted periodic monitoring. Results: Patient positioning execution accuracy increased from 80% to 100%; cognition of patient positioning increased from 88% to 100%. Conclusions: The operating room committee adopted the proposed procedures and they are now SOPs in all operating rooms at our hospital. We suggest including the SOPs developed in this project in continuous education programs and urge making well-designed positioning assistance devices available to protect patient safety during surgery.