背景　吞嚥障礙病人藉由鼻胃管灌食以提供營養，重複放置時常見重插管困難、胃糜爛等情形。目的　本單位在2012年第一季鼻胃管滑脫率為2.26%，相較前一年顯著上升且拔管後須重插比例高，故本專案目的在提升鼻胃管管路照護安全進而降低鼻胃管滑脫率。解決方案　經現況分析後歸納出滑脫率高的主因為：（1）照顧者對衛教內容不瞭解、（2）照顧者解除約束及（3）轉位不當及翻身時未注意。故擬定解決辦法有：（1）修訂鼻胃管管路安全照護作業標準；（2）製作雙語鼻胃管固定與擺放位置及約束衛教單張（英、印尼版）；（3）拍攝雙語鼻胃管固定與擺放位置及約束衛教教學影片（中、印尼版）；（4）製作創新簡易的約束替代工具：約束球；（5）製作創意警示標語之床頭卡；（6）加強提醒鼻胃管固定及擺放位置。結果　鼻胃管滑脫率由改善前2.26%降至0.77%，效果維持為0.75%，評值照顧者衛教後全部瞭解之比例達100%。結論　經文獻查證、確立問題並經由專案成員創意發想的執行解決方法，使得專案的成果不僅達成專案的目標，更提升了護理品質。

Background & Problem: Nasogastric (NG) tubes are used for providing nutrition to patients who have difficulties swallowing. However, the difficult process of repeatedly inserting NG tubes may lead to gastric erosions. Purpose: The rehabilitation ward in this study had an NG tube slippage rate of 2.26% in 2012, significantly higher than the same rate in 2011. A proposal was developed to design better techniques for nurses to perform NG tube insertions in order to decrease the rate of NG tube slippage. Resolution: The following were identified as the major causes of NG tube slippage: (1) caretaker is unfamiliar with NG tube care instructions, (2) caretaker disengages NG tube constraints, and (3) improper rotation of patients or carelessness when turning patients. Therefore, the following solutions were proposed: (1) establish an NG tube safety standard operating procedure, (2) publish bilingual (English and Bahasa Indonesia) pamphlets providing instructions on the correct method of securing and placing the NG tubes, (3) make bilingual (English and Bahasa Indonesia) instructional videos showing the correct method for securing and placing the NG tubes, (4) fabricate a novel tube constraint tool (the constraint ball) that is easy to use, (5) install creative bedside NG tube warning signs, and (6) reinforce the importance of NG tube constraint and placement among caretakers. Results: The NG tube slippage rate was reduced from 2.26% to 0.77%, and was maintained at 0.75% during the follow- up period. The caretaker assessment further showed 100% understanding of the implemented NG tube safety procedures. Conclusion: This proposal was established using literature research, problem identification, and creative problem solving to achieve an effective reduction in NG tube slippage as well as to enhance nursing quality.