病人安全通報系統跌倒事件分析

Analysis on Fall Incidences from Patient Safety Reporting System

本研究之目的是針對某醫學中心住院病人之跌倒事件做分析，進而了解跌倒高危險群病人之特質、服用之藥物與其跌倒事件發生的相關性，以及影響病人跌倒後傷害程度差異之因素，以作為醫護人員今後預防跌倒事件之參考。研究方法採回溯性調查方式，回顧台北市某醫學中心從民國94年至民國95年6月間跌倒意外通報事件表及病歷資料，共蒐集97位跌倒病人，101件跌倒事件的資料收集﹔包含病人基本資料與跌倒事件發生當時相關資料。發生密度以個數及百分比呈現，統計以卡方檢定進行組間比較。研究結果發現跌倒高危險族群多為高齡、獨立活動能力差、視力狀況差、服用跌倒相關藥物者，且以內科病患居多。跌倒大多發生在病床邊，以病人在行進過程中最常發生，發生時間在大夜班居多，且發生時病人意識狀況多半為清醒，在跌倒傷害方面以中度傷害的居多，發生時有無陪伴者在旁與跌倒後傷害程度呈現差異（P=0.095<0.1）。結論：住院病人跌倒事件是醫院照護上極為重要的問題，醫護人員應了解跌倒相關因素以預防跌倒高危險病患跌倒之發生，以促進病人安全與提昇醫療品質。本研究建議看護者衛教也應列為預防跌倒的重要措施。

The objective of this study is to report inpatient falls in a medical center in order to identify the characteristics of high-risk patients, to correlate medication effects with occurrence of incidents, and to analyze the factors that may affect outcomes of fall injuries. Conclusions generated from this study may provide caregivers valuable information in preventing fall incidence. This study was performed by retrospective investigation; fall incidents which occurred from January 2005 to June 2006 in a medical center located in Taipei were enrolled. 97 patients and 101 fall incidents were reported. The demographics, characteristics, and other related information of fall patients were documented and analyzed. The densities of incidents are presented and are compared within groups by Chi-squared test. It is found that high-risk patients are typically the elderly from the internal medicine ward; patients are often with poor mobility and poor eyesight. Many fall incidences are related to medications with side effects of disequilibrium. Fall incidents often occurred near the bedside, in walking, during the night shift, and under clear consciousness; most of the fall incidents caused intermediate injuries. It is found that patients with and without companions during fall incidents show significant difference in the severity of fall incidence (p=0.095). We conclude that inpatient fall is a critical issue that caregivers should pay special attention to. It is also crucial for caregivers to understand the related factors which can cause the fall incidence. To improve patient safety and healthcare quality, the study suggests that education to families and non-professional caregivers is an important strategy to prevent fall incidence.