探討以風險管理模式改善院內跌倒發生率之專案

A project on decreasing falls by the application of risk management model

跌倒是醫療院所發生意外事件中的首位，更是醫院管理中之高風險高成本之事件。因此，本專案以回溯法進行95年1月至10月病人跌倒資料蒐集，並依據風險管理模式，彙整造成病人跌倒之導因包括：病人面、人因面、硬體面、環境面等四大因素。而透過風險管理之失效模式分析及80/20法則辨識最高的危險項目共有18項。經落實組織病人安全之風險管理文化、教育訓練與評核、以及作業標準化與定期稽核之行動方案後，對護理人員改善院內跌倒有顯著成效，病患之跌倒件數由每月的5.6件下降為2.4件，而醫院透過風險管理模式建立一套有效之預防跌倒照護措施，不僅提高照護品質，避免醫療糾紛，同時也降低病患之合併症，達到跌倒意外事件之品質管控。

Accidental falls are the most commonly encountered accident in the hospital. It is recognized as the high-risk event and is evidently associated with high cost in hospital management. Herein, in this special project, we retrospectively collected the pertinent information concerning the accidental falls in the hospital including the hospital environment, hardware in the ward, floor surface and patient’s demographic factors between January and October 2006. By applying the failure mode analysis and 80/20 principle we identified a total of 18 items of high risk attributes related to accidental falls in the hospital. Furthermore through the efforts to enforce the education and training of the hospital staff regarding the patient safety and risk management, and by establishing work place standardization and conducting regular auditing for compliance, our project has demonstrated significant improvement of patient safety in the hospital to reduce the fall incidents in our hospital. Currently, the incidence of accidental falls or tumbles in our hospital has been reduced from 5.6 to 2.4 incidents per month. The risk management model established here not only can improve the quality of patient care but also will avoid medical dispute and improve the patient’s and family’s satisfaction.