目的：燒傷重症的病人，氣管內管的留置是醫療常見的處置。非計劃性拔除氣管內管對病人有著極大的傷害，對醫院成本的消耗以及醫療照顧上更是增加不少困境。此專案以病人為中心之照護及病人安全考量，進行改善策略，降低非計劃性氣管內管自拔的發生率小於等於 0.20%。 方法：某醫院燒傷加護中心 2010年至 2012氣管內管拔管發生事件，氣管內管拔管發生率有逐年上升至 0.30%。透過分析及確立非計劃性拔除氣管內管要因，再進行對策措施之研擬，執行策略包括：(一)實施約束標準作業流程及技術示範之在職教育、(二)將鎮靜評估量表紀錄列入交班，作為醫囑鎮靜給藥之建議、(三)實施氣管內管固定標準及技術演練、(四)解約束後評估及警示防拔管之措施，最後進行成效評值。 結果：非計畫性氣管內管拔管發生率由 0.30%降至 0.16%，達設定之目標。對於意識清楚但卻表達不便之病人，溝通卡是一項重要選擇之工具，其使用率達 100%。約束評估及鎮靜用藥列入必要交班，監測結果達 100%。 結論：透過實施氣管內管固定標準、在職教育、技術演練、溝通卡及將約束評估與鎮靜用藥列入必要交班，可減少非計劃性氣管內管拔管。

OBJECTIVES: Endotracheal intubation is a common procedure as part of burn care. Unplanned extubation pose a great risk to patients and result in an increase in hospital costs. Based on the concept of patient-centered care, our aim was to develop a strategy to reduce the incidence of unplanned extubation to 0.20% or less. METHODS: Retrospective analysis revealed that the incidence of unplanned extubations had gradually increased to 0.30% in our burn center from 2010 to 2012. Using the Fishbone diagram and Pareto chart, we determined the main reasons for unplanned extubation and instituted measures for improvement including: 1)implementation of standard procedures and in-service education with technical demonstrations, 2) handing over the results of the sedation assessment scale to the next shift where they could be used as a reference for sedation orders from physicians 3)implementation of standard procedures and skill training for endotracheal tube fixation, and 4)assessment after release from restraint and evaluation of measures to warn subsequent shifts about unplanned extubation so that it might be prevented. RESULTS: We achieved the anticipated goal, as the incidence of unplanned extubation was reduced from 0.30 to 0.16%. For conscious patients with difficulties in expression, communication cards were used. Assessment of restraint and warning the next shift were performed 100% of the time. CONCLUSIONS: Implementation of standards for endotracheal tube fixation, education, technical training, communication cards and assessment of restraintreduced the incidence of unplanned endotracheal tube extubation in our burn center.