胰島素治療是血糖控制最有效的方法之一，若操作技術不當或錯誤極易造成血糖不穩定，嚴重時將危害生命。故本專案旨在提升糖尿病人初次自行胰島素注射正確率，執行期為2012年4月至10月，經現況分析發現主要原因為胰島素注射護理技術作業準則不合時宜、護理師指導時間匆促、無追蹤機制、注射步驟繁瑣與衛教單張字多圖少。研擬解決方案有拍製多媒體影音教學光碟、提供胰島素注射叮嚀卡與創意圖卡、修訂護理技術作業準則及建立電訪追蹤機制。經改善措施後，糖尿病人初次自行胰島素注射正確率由的65.22%提升至92.19%。專案結果不僅確保病人用藥安全，亦提升糖尿病照護品質。

Insulin injection is one the most effective method for blood sugar control. The inappropriate or wrong operation might cause unstable blood sugar, or even threaten to life. The project was intended to improve the accuracy of initial auto-insulin injection in diabetic patients between April 2012 and October 2012. After analysis, the main problems were inappropriate insulin injection standard, inadequate education time by nurses, no follow-up mechanism, complicated injection procedure and full of words and lack of pictures on the health education leaflet. The resolutions included multimedia teaching disc, insulin injection reminding card and creative card, nursing technique standard modification, and telephone follow-up mechanism. After this improvement, the accuracy of initial auto-insulin injection elevated from 65.22% to 92.19%. The project not only ensures the medication safety but also elevates the care quality in diabetic patients.