PDCA循环由美国管理学家戴明提出,已经成为护理质量管理的基本方法,其体系运转的基本方式是以计划(plan)、执行(do)、检查(check)、处理(ac-tion)的科学工作程序进行管理循环,每次循环都将起点提高到一个新的水平~[1]。随着社会人口老龄化,老年人的安全问题越来越受到关注,老年住院患者置管率高,住院时间长,容易出现各种并发症及意外。意外拔管是指导管意外脱出,或未经医护人员 The PDCA cycle, proposed by the American management scientist Deming, has become the basic method of nursing quality management. The basic way of running the system is to plan, do, check, ac- tion Scientific work procedures for management cycle, each cycle will be the starting point to a new level ~ [1]. With the aging of the society, the safety of the elderly is getting more and more attention. The elderly patients in hospital have a high rate of catheterization and long hospital stay, which is prone to various complications and accidents. Accidental extubation refers to accidental catheter extubation, or without medical staff