RESUMO
Accidental extubation is an emergency situation occurring in patients on mechanical ventilation. In order to know the reality of our unit, a retrospective revision of all patients intubated during the second semester of the year 2000 was carried out and resulted in 5,98 percent accidental extubation rate. With the goal to diminish the incidence of accidental extubation and displacement of the endotracheal tube in patients of the general intensive care unit, an intervention program was designed based on continuos improvement of quality (1). The program was evaluated in june, 2001, achieving a 2,72 percent decrease in incidence. Despite the fact that our intervention has had the impact of reducing accidental extubations by 45 percent, this is not considered statistically significant most likely due to the studyïs short observation period