某教學醫院住院病患跌倒事件之調查報告

A Investigation of In patient’s Fall Incidents in a Teaching Hospital

本調查之目的係針對某教學醫院民國79年至87年之43位跌倒住院病人，探討其（１）個人屬性變項特質（2）影響病患跌倒之相關因素，以跌倒意外事件報告單、病歷及”跌倒因素分類表”進行調查，資料以百分比、平均數及標準差分析，主要發現為：（1）個人屬性方面：65歲以上之老人跌倒率最高（48.84％)，性別以男性居多（62.8％），職業以無較多（69.8％)；(2)相關因素方面：(1)使用之藥物以鎮定安眠劑較多(2)環境方面：跌倒地點以床邊較多。跌倒當時，現場有無陪伴者，無明顯差異(3)時間：以6AM-8AM及2PM-4PM發生人數略多，而跌倒發生於入院一週內的有48.8%(4)診斷方面：以心臟血管疾病較多，科別：以內科發生率較高。根據結果，提出建議重點為(1)主動幫忙自我照顧有困難的病患，列入交班及依情況調整巡視時間及頻率；(2)需教導病患或陪伴者上下床之方法、輔助物的使用及注意事項；(3)視病患身高調整病床高度，浴室常設扶手座椅；(4)將’預防跌倒’列入在職教育課程。

The purpose of the investigation is to determine the characteristics of risk factors, which contribute to the incidence of falls in a general teaching hospital. By reviewing forty-three incident reports concerning about patient falls , nursing records, and collected data in the form of the characteristics of the risk factor of falls, some nursing interventions related to fall prevention are suggested. The result of the retrospective study was conducted to identify patient’s age, sex, occupation, marriage status and related factors like drugs, time of fall, place of fall, visitors at the time of fall, and diagnosis which was associated with the incidents. Based on these study findings: most of the patient are male, over sixty-five years old and unemployed. The related factors: drugs-most of them took tranquilizers; environment-most accidents happened near the bed; time-most accident occurred between 6 a.m. to 8 a.m. and 2 p.m. to 4 p.m.; Diagnosis-most patients have cardiovascular disease. We suggest to help patients who have difficulties in self care, adjust the time of nursing rounds, teach patients and visitors how to get on and out of bed. Adjust the height of bed and the equipment in the bathroom to fit the individual need, list “fall prevention” in the training course.