非計劃事件的預防與監測是醫院品管的重要工作，臺北榮民總醫院冠狀動脈加護 中心， 八十三年度管路滑脫調查結果發現， 靜脈注射管路的滑脫率最高佔所有管路滑脫之 34%， 鑑於靜脈注射是現今治療病患不可或缺的部分，且本中心之病患可說 100% 需要接受 靜脈注射治療。故以此專案自八十四年一月開始擬訂並執行非計劃性靜脈重注率監測。經過 持續改進計劃的實施之後，整個監測的結果一直到八十五年五月以後，非計劃性靜脈重注率 由未執行計劃前的 51%， 降低為八十五年五月 37%、六月 28%、七月 35%， 均已顯著低於 40% 閾值，可確知已達到改善的目標。此外在監測的過程中發現，造成非計劃性靜脈重注的 主要因素為：注射針管凝固、注射液外滲、局部災症、管路自拔等等情況。經過改進計劃的 實行後，注射針管凝固及局部炎症之發生率已降低；但注射液外滲及管路自拔的發生率未見 減少，是繼續改進要努力的方向。由於在醫院裡大部分病患需接受靜脈注射治療，故此類品 質監測計劃若能推行於全院，則必能達到更廣泛的效益。

　　　　　Prevention and monitoring of incidental events is an important part of hospital quality control. The 1994 annual statistics for spontaneous detachment of catheters in the coronary care unit of Veterans General Hospital-Taipei showed that detachment of intravenous catheters had the highest incidence, accounting for 34% of all catheter detachment. Because almost all patients in our CCU need intravenous catheterization, we introduced a plan to monitor the unplanned intravenous re-injection rate. After continuous monitoring and execution, the monthly unplanned intravenous re-injection rate fell below the 40% threshold. In the pre-monitoring era the rate was 51%; in May 1996 it was 37%, in June 1996 28%, and in July 1996 35%, which all reached the goal we set. We also found that the major causes for unplanned intravenous re-injection were: coagulation of puncture needle, extravasation of injection fluid, local inflammation, and spontaneous removal by patients themselves. After executing the plan, the incidence of puncture needle coagulation and local inflammation decreased, but that of extravasation of intravenous fluid and removal by patients was still high, so we must continue to seek a suitable method to prevent unplanned intravenous injection. Because the majority of patients in hospital need to receive intravenous catheterization, more benefit could be gained after introducing such planning to all the sections in the hospital.