背景：加護重症病人因疾病嚴重導致呼吸衰竭高達80%以上，須藉由氣管內管處置治療，期間若發生非計畫性氣管內管移除，不僅造成治療時間延長，住院天數增加，嚴重將危害生命安全。目的：本專案旨在降低加護重症病人非計畫性氣管內管移除率。方法：經由2011年非計畫性氣管內管移除之20個案例，分析原因後，應用團隊資源管理模式中，領導、情境監測、互相支援及溝通等手法，擬定改善措施。結果：經由對策措施介入，2012年1月~2013年5月非計畫性氣管內管移除降至12例，由2011年0.27%下降至2012年的0.14%，達專案目標。結論/實務應用：本專案應用團隊資源管理模式不僅降低非計畫性氣管內管移除率，增加病人安全，也經由執行對策過程中，達到正向溝通的工作氛圍。

Background: There are more than 80% patients who stay in Intensive Care Unit (ICU) has to proceed endotracheal intubation treatment due to server respiratory failure. Unplanned removal of endotracheal tube during stay in ICU not only could prolong the treatment period and increased the length of stay in hospital, but also threaten life. Purposes: The purpose of this study is to reduce the rate of unplanned endotracheal tube removal in ICU. Methods: After cause analyzing from the 20 cases who were suffered unplanned endotracheal tube removal in ICU in 2011. The team resources management mode was utilized to build up certain interventions in order to improve this situation, such as leadership, situational monitoring, team supporting and communication. Results: After engaging interventions from January 2012 to May 2013, the rate of unplanned endotracheal tube removal has decreased from 0.27% in 2011 to 0.14% in 2012 by 12 cases. This reached the study goal. Conclusions: This study not only applied the team resources management mode to prevent unplanned endotracheal tube removal which had achieved significant positive result, but also increased patients’ safety. Besides, positive negotiation climate in working place had established through management strategy.